itiney 


GENERALIZED  PAIN 


CLINICAL 

SYMPTOMATOLOGY 

OF 

INTERNAL  DISEASES 


PART  II 

GENERALIZED    PAIN1 

I 

PROF.   DR.   NORBERT   ORTNER 

VIENNA 

Only  Authorized  Translation  Into  the  English  LanguagQ 
of  the  2nd  German  Edition 

BY 
FRANCIS  J.  REBMAN 

WITH  AN  INTRODUCTION  BY  THOMAS  WEBSTER  EDGAR,  M.D., 

NEW  YORK 


NEW  YORK 
MEDICAL  ART  AGENCY 


COPTBIGHT,   1922 

BY  FRANCIS  J.  REBMAN 
NEW  YOBK 


Printed  in  America 


AUTHOR'S  PREFACE 

THE  favorable  reviews  of  my  book  on  "Ab- 
dominal Pain"  which  have  appeared  in  the  medi- 
cal journals  have  encouraged  me  to  write  this 
Second  Part,  dealing  with  "Generalized  Pain." 
In  these  two  volumes  I  have  carefully  and  clearly 
discussed  all  the  salient  features  and  symptoms 
of  painful  internal  diseases,  and  I  sincerely 
trust  that  the  reader  will  derive  that  benefit 
which  it  was  my  intention  to  convey. 

NOEBEET  OETNEE. 

Vienna. 


INTRODUCTION 

"GENERALIZED  PAIN/'  Part  II  of  Clinical 
Symptomatology  of  Internal  Diseases,  as  trans- 
lated from  the  original  German,  represents  a 
complete  symptomatology  of  all  the  painful  sen- 
sations experjenced  by  the  human  organism,  with 
the  exception  of  the  abdominal  region,  which  is 
discussed  in  a  separate  volume. 

Prof.  Dr.  Ortner  has  made  it  possible  by  this 
book  for  the  physician  to  appreciate  the  selective- 
ness  of  the  symptom  pain,  and  the  text  may  be 
used  as  a  guidance  in  the  differential  diagnosis 
of  many  pathological  conditions  that  heretofore 
have  been  clouded  by  a  multiplicity  of  vague  un- 
charted painful  sensations. 

This  book  "analyzes  pain,"  and  may  be  used 
to  great  advantage  by  the  physician  when  ques- 
tioning his  patient. 

The  more  than  kind  reception  accorded  Part 
I,  "Abdominal  Pain,"  undoubtedly  will  serve  as 
a  fitting  introduction  to  Part  II. 

Prof.  Dr.  Ortner  has  made  the  subject  of  gen- 
eralized pain  preeminently  his  own. 

The  translator  has  chosen  clear  and  simple 
English,  making  the  book  easier  to  digest  and 

vii 


Vlll  INTRODUCTION 

more  readily  assimilated.  The  long,  interwoven 
sentences  of  the  original  German  have  been 
rendered  short,  presenting  to  the  reader,  however, 
the  original  text  in  all  its  exactness. 

THOMAS  W.  EDGAB,  M.D. 
New  York  City. 


TRANSLATOR'S   PREFACE 

DR.  ORTNER  divides  his  book  on  Clinical  Symp- 
tomatology into  two  parts,  viz.:  "Abdominal 
Pain"  and  "Generalized  Pain."  The  first  part 
deals  entirely  with  pain  which  manifests  itself  in 
the  abdominal  region  of  the  human  body  and  all 
the  subdiaphragmatic  organs  contained  therein. 
This  volume  was  published  in  the  early  part  of 
1922  and  has  established  itself  firmly  in  the 
medical  book  market. 

The  second  part  is  now  ready  for  distribution. 
It  deals  with  pain  felt  by  the  patient  in  those  parts 
of  the  anatomy  which  are  not  included  in  the  first 
volume,  and  the  author  very  appropriately  gives 
it  the  title  of  "Generalized  Pain." 

The  language  employed  is  simple  and  not  too 
technical,  a  quality  which  will  readily  appeal  to 
the  profession.  The  forthstanding  features  of 
the  book  are  the  marvelous  clinical  experience 
of  the  author,  which  he  gives  unstintingly  to  the 
reader,  and  the  clever  way  in  which  he  weaves 
the  localized  manifestations  of  pain  and  their 
irradiations  into  adjacent  and  remote  parts  to- 
gether into  a  solid  unit.  The  two  volumes  com- 
bined form  a  perfectly  balanced  whole  which 

be 


X  TRANSLATOR'S    PREFACE 

can  be  conscientiously  recommended  to  those  who 
seek  reliable  information  on  the  subject. 

I  sincerely  hope  that  the  book  will  meet  with 
the  approval  of  the  medical  men  of  this  country, 
and  that  my  labors  as  translator  will  reap  a  well- 
earned  appreciation  by  the  thoughtful  student  of 
symptomotology.  The  book  is  devoid  of  pad- 
ding and  redundancies.  Every  sentence  is  care- 
fully weighed  and  a  necessity  in  its  place,  so  that 
without  it  the  totality  of  the  subject  would  be 
disturbed,  if  not  seriously  injured.  I  think  that 
both  "Generalized  Pain"  as  well  as  "Abdominal 
Pain"  possess  the  inherent  centrifugal  power  of 
success. 

I  also  take  this  opportunity  to  thank  Dr. 
Thomas  Webster  Edgar  for  his  great  kindness 
and  exceeding  patience  in  looking  over  the  proof- 
sheets. 

THE  TRANSLATOR. 
New  York. 


TABLE   OF   CONTENTS 

PAGE 

PAIN  IN  THE  HEART  AND  IN  THE  CARDIAC  REGION  . .  1 

Pain  in  the  Thoracic  Wall 1 

Moderate  Cardiac  Pain  2 

Anginoid    Pain    10 

Angina  Pectoris  (Stenocardia)   26 

Painful  Attacks  Resembling  Angina  Pectoris. .  47 

Status  Anginosus  71 

PAINS  IN  THE  SACRUM 73 

PAINS  IN  THE  COCCYGEAL.  REGION  (Coccygodynia) . .  103 

PAINS  IN  THE  SHOULDER 105 

Pains  in  the  Region  of  the  Shoulder-Joint  ....  105 

Pains  in  the  Region  of  the  Shoulder-Blade 119 

Pains*  between  the  Shoulder-Blades 122 

Pains  in  the  Fossa  Supraclavicularis  and  Su- 

praspinata  138 

PAINS  IN  THE  BACK 146 

PAINS  IN  THE  NECK 169 

Feeling  of  Constriction  in  the  Neck 185 

PAINS  IN  THE  NAPE  OP  TJEE  NECK 189 

PAINS  IN  THE  CHEST 195 

Girdle  Sense 204 

Pains  in  the  Region  of  the  Ensiform  Appendix  218 

Retrosternal  Pain  and  Feeling  of  Pressure. . . .  222 

Laterosternal  Pain    232 

Pleurodynia    234 

Sudden  Violent  Pain  in  the  Chest 250 

Pressure,  Oppression  in  the  Chest 255 

PAINS  IN  THE  EXTREMITIES 257 

Paresthesia  of  the  Extremities 266 

Cold  Hands  and  Feet 295 

xi 


Xll  TABLE  OF  CONTENTS 

MM 

Dead  Fingers  296 

Pains  in  the  Bloodvessels 297 

Dyspragia,  Intermittent  Angiosclerotic 298 

Lancinating  Pains  in  the  Extremities 349 

Painful  Muscular  Cramps 355 

Painful  Cramps  in  the  Calves 355 

Pain  in  the  Foot  or  Hand . .  359 

Pain  in  the  Axilla  and  Groin 360 

MUSCULAR  PAIN 362 

Trismus  382 

Tetanic  Muscular  Cramps 387 

PAINS  IN  THE  BONES  395 

So-called  Rheumatoid  Pains 431 

Brittleness  of  Bones 432 

Swellings  in  the  Bones  433 

Drumstick  Fingers  and  Osteoarthropathie  Hy- 

pertrophiante   * 435 

ARTICULAR  PAINS 446 

I.  Acute  Articular  Pains 446 

Swelling  of  the  Lymphatic  Glands  in  Acute 

Articular  Diseases 455 

Articular  Diseases  Not  Metastatic 468 

II.  Chronic  Articular  Pains 478 

Heberden's  Nodes   501 

HEADACHE  509 

Headache  of  Cranial  Origin 509 

Nocturnal  Headache  514 

Posttraumatic  Headache   515 

Headache  of  Endocranial  Origin 516 

Headache  and  Increased  Cerebral  Pressure. . . .  530 

Headache  Due  to  Remote  Causes 536 

Migraine    559 

Diagnostic  Value  of  Localizing  Headaches 568 

INDEX  —                                                                .  571 


GENERALIZED  PAIN 


Pain  in  the  Heart  and  the  Cardiac  Region 

Pains  in  the  Thoracic  Watt. — If  a  patient 
complains  about  pain  in  the  cardiac  region,  we 
should  first  of  all  ascertain  whether  this  pain  is 
really  located  in  the  heart  itself,  or  its  muscular 
system,  or  is  erroneously  claimed  by  the  patient 
to  emanate  from  these  organs. 

In  this  respect  the  existence  of  a  pain-pro- 
voking disease  in  the  soft  or  bony  coverings 
over  the  heart,  or  in  the  skin,  the  mamma,  the 
muscles,  the  intercostal  nerves,  the  ribs  or  even 
the  sternum,  may  be  excluded.  A  careful  ex- 
amination and  a  proper  knowledge  of  the  symp- 
tomatology in  such  cases  will  quickly  solve  the 
problem.  The  reader  is  here  referred  for  par- 
ticulars to  the  chapters  on  "Pain  in  the  Chest" 
and  "Pain  in  the  Bones." 

What  I  wish  to  emphasize  at  once  is  the  fact 
that  women  who  have  abnormally  large  breasts, 
with  the  left  mamma  still  more  developed,  com- 
monly complain  of  pain  in  the  cardiac  region 
or  in  the  heart  itself  which  is  of  a  pressing  or 

i 


2  GENERALIZED    PAIN 

oppressive  nature.  These  patients  are,  as  a 
rule,  rather  stout  in  general,  and  suffer  from 
difficulty  in  breathing,  especially  when  making 
any  kind  of  bodily  effort,  conditions  which 
often  lead  to  a  mistaken  diagnosis  of  an  affec- 
tion of  the  cardiac  muscles,  or  an  anatomical 
defect  of  the  heart  proper.  I  have  come  across 
such  errors  repeatedly. 

The  suspicion  that  the  pain  is  caused  by  the 
over-heavy  mammary  glands  may  be  based  on 
the  following  facts:  (1)  an  abnormal  develop- 
ment of  the  mamma;  (2)  the  patients  often 
admit,  without  being  asked,  that  the  pain  is 
relieved  as  soon  as  they  raise  the  mamma  with 
the  hand;  (3)  when  the  patient  is  lying  on  her 
back  the  pain  continues,  but  disappears  when 
the  mamma  is  raised  with  a  suspensory. 

Pain  in  the  cardiac  region  may  also  be  caused 
through  mechanical  friction  of  the  dress  on  the 
nipple.  As  soon  as  the  cause  is  removed,  the 
pain  vanishes. 

Moderate  Heart  Pain. — If  we  are  satisfied 
that  the  affection  is  not  located  in  the  thoracic 
frame,  we  have  ground  to  believe  that  the  seat 
of  pain  is  to  be  found  in  the  heart  itself,  or  in 
its  large  blood  vessels.  But  we  should  also  think 
of  a  reflex  action  arising  from  a  disease  in  some 
neighboring  or  even  distant  organ. 

The  pain  varies  in  intensity.  Sometimes  it 
consists  only  of  a  slight  sensation  of  incon- 


HEAET  3 

venience,  sometimes  it  is  moderate  (subacute), 
while  at  other  times  it  is  violent  (acute). 

Acute  Pericarditis. — Most  likely  we  are  deal- 
ing with  an  acute  involvement  of  the  heart, 
generally  of  the  pericardium,  but  it  may  also 
be  myocardiac  or  endocardiac  in  its  nature.  In 
acute  pericarditis  the  patient  complains  of  stab- 
bing pains,  and  pressure  in  the  region  of  the 
heart.  In  some  rare  cases  the  pains  assume  a 
very  intense  and  troublesome  character.  But 
more  about  this  in  another  place.  The  pains 
just  described  may  also  be  present  in  subacute 
and  chronic  pericarditis.  In  the  majority  of 
cases,  however,  they  seem  to  be  absent  even 
where  a  chronic,  chiefly  tuberculous  inflamma- 
tion of  the  pericardium  exists.  But  nearly  every 
kind  of  tuberculous  serositis  (pleuritis,  perito- 
nitis) runs  a  painless  course.  A  pneumoperi- 
cardium  or  a  hematopericardium,  it  is  needless 
to  say,  will  also  produce  pain  in  the  region  of 
the  heart. 

Acute  Myocarditis. — Similar  pains,  generally 
accompanied  by  slight  fever,  may  be  observed 
in  every  case  of  myocarditis  acuta,  when  an 
abscess  formation  in  the  myocardium  is  present, 
coupled  with  or  following  an  ulcerous  septic 
endocarditis. 

Overexertion.  Paroxysmal  Tachycardia.  — 
Slight  pain  in  the  cardiac  region,  generally  de- 
scribed as  stabbing,  piercing,  painful  pressure 


4  GENERALIZED   PAIN 

at  times  follows  in  the  wake  of  an  acute  over- 
exertion,  i.e.,  an  acute  straining  of  the  heart  due 
to  sport  or  gymnastic  exercises,  intense  psychic 
excitement  (increase  in  blood  pressure),  or 
after  an  attack  of  tachycardia.  These  troubles, 
especially  oppression  in  the  chest,  manifest  them- 
selves naturally  only  when  a  constitutionally 
weak,  untrained  heart  is  suddenly  subjected  to 
unusual  exertion:  shortness  of  breath,  inability 
to  draw  a  long  breath,  dryness  in  the  mouth, 
constant  irritation  to  clear  the  throat  with 
shreds  of  blood  in  the  mucus,  abnormally  large 
content  of  urates  in  the  urine. 

Similar  conditions  prevail  when  the  heart  is 
afflicted  with  a  pre-existing  anatomical  defect 
and  is  suddenly  subjected  to  unusual,  severe 
demands;  but  they  may  also  be  due  to  an  acute 
loss  of  tonus  in  an  otherwise  normal  heart.  A 
thin,  scarcely  palpable  pulse,  cold  sweats,  pal- 
lor of  the  face,  coldness  of  the  point  of  the 
nose,  cold  and  clammy  hands  and  feet,  short 
breath,  angina,  oppression  in  the  region  of  the 
heart,  vertigo,  dizziness,  eventually  acute  dilata- 
tion of  the  heart,  systolic  murmurs,  high  blood 
pressure,  all  these  may  be  added  to  the  afore- 
said symptoms. 

Acute  Insufficiency  of  the  Suprarenal  Cap- 
sules.— I  refer  here  to  that  fierce  pain  which  is 
described  by  some  authors  as  a  sign  of  insuffi- 


HEART  O 

ciency  of  the  suprarenal  capsules  in  Addison's 
disease.    Personally,  I  have  never  observed  it. 

But  an  abnormally  irritable  heart  may,  even 
without  previous  overexertion,  give  rise  to  anal- 
ogous complaints  of  pain  or  palpitation,  espe- 
cially if  hypoplasia  be  present.  Such  an  over- 
excitable  heart  may  easily  be  traced  by  a  pro- 
nounced and  spreading  apex  beat  (in  cardiac 
hypoplasia  even  by  a  normal  or  also  abnormally 
weak  apex  beat),  by  an  abnormally  loud  second 
aorta  tonus,  often  by  a  temporary  systolic  sound 
over  the  apex  or  the  pulmonary  artery,  by  in- 
clination to  tachycardia,  by  a  choppy,  peripheral 
pulse,  or  by  other  vasomotoric  symptoms. 

A  pain  which  is  strictly  confined  to  the  apex 
and  rendered  more  acute  by  external  pressure 
may  also  be  the  symptom  of  a  chronic  affection 
of  the  cardiac  muscle,  in  fact  a  definite  sign  of 
a  cardiac  aneurysm. 

Of  high  diagnostic  interest  are  those  cases  in 
which  after  a  pronounced  stenocardiac  attack 
pressure,  oppression  and  moderate  pain  in  the 
cardiac  region  irregularly  persist.  In  most  cases 
a  slight  rise  in  the  temperature  will  be  observed, 
the  objective  examination  shows  pericarditic 
friction,  eventually  the  formation  of  a  fluid  exu- 
date  of  the  pericardium,  i.e.,  a  clear  case  of 
epistenocardiac  pericarditis,  caused  either  by  an 
embolism  of  the  branches  of  the  coronary  artery 
due  to  a  pericardial  infarct,  or  by  a  partial 


6  GENERALIZED   PAIN 

chronic  aneurysm  of  the  heart.  In  the  absence 
of  pericarditis  a  similar  symptom  complex,  i.e., 
pressure,  oppression,  slight  pain,  may  endure 
after  an  anginotic  attack.  The  cause  for  this 
will  be  found  in  an  epistenocardiac  myocarditis 
(myomalacia)  coupled  with  dilatation  of  the 
heart.  Its  presence  is  indicated  by  a  slight  rise 
in  the  temperature.  In  some  rare  cases  these 
pains  assume  an  intensely  bothersome  character. 

I  wish  to  emphasize  a  fact  which  seemingly 
has  not  as  yet  been  properly  appreciated,  i.e., 
if  a  patient  complains  of  a  sudden,  solitary  or 
irregularly  recurring  pressure  or  stitch  in  the 
cardiac  region  or  behind  the  sternum,  the  possi- 
bility of  extrasystolic  contractions  must  not  be 
overlooked  as  the  probable  cause  of  such  solitary 
sensations.  According  to  my  own  experience, 
the  so-called  frustaneous  contractions  are  the 
primary  exciting  factors  in  these  sensations,  in 
conjunction  with  all  the  other  extrasystolic  con- 
ditions. This  seems  to  me  an  indirect  proof 
that  cardiac  pain  may  be  the  result  of  an  ische- 
mia of  the  myocardium.  The  same  may  be  said 
about  the  presence  of  cardiac  pain  in  hemorrha- 
gic  anemia. 

A  stitch  in  the  region  of  the  heart  may,  how- 
ever, be  a  purely  nervous  symptom,  recognizable 
when  it  is  located  to  the  left  above,  but  without, 
the  absolute  heart-dulness,  or  at  the  point  of  the 
apex,  where  it  is  joined  by  a  localized  sensible 


HEART  7 

pressure,  i.e.,  an  hyperesthesia  of  the  membrane 
over  the  heart-dulness. 

It  is  a  well-known  fact  that  pain  in  the  car- 
diac region  of  a  convulsive,  oppressing  character 
is  often  the  sequel  of  some  violent  psycluc  emo- 
tion. But  it  is  well  to  remember  that  such 
emotions  may  lead  to  real  anatomical  pain,  e.g., 
angina  pectoris. 

These  stabbing  pains  cannot,  however,  always 
and  definitely  be  ascribed  to  nervous  conditions; 
they  may  just  as  well  be  the  accompanying 
symptom  of  a  chronic  anatomical  disease,  such 
as  chronic  myocarditis,  myofibrosis,  myodegen- 
eration  of  the  heart,  arteriosclerosis,  renal  heart 
with  increased  blood  pressure,  affections  of  the 
mitral  or  aortic  ostium  (the  latter,  however, 
produce  pain  rather  behind  the  sternum),  a 
total  pericardial  concretion  with  the  heart  (only 
in  exceptional  cases),  fatty  heart  (polysarcia 
cordis  et  myodegeneratio  adiposa),  the  beery 
heart,  cardiac  syphilis,  affection  of  the  heart  due 
to  growing,  dropping  heart,  also  every  relatively 
weak  heart,  in  fact  all  morbid  processes  which 
are  connected  with  the  left  ventricle.  They  all 
lead  to  pains  in  the  region  of  the  heart,  and 
behind  the  sternum,  to  a  retrosternal  sensation 
of  pain,  eventually  to  a  painful  dyspnea. 

Enteroptosis,  above  all  sclerosis  of  the  coro- 
nary artery,  frequently  produce  similar  sensa- 
tions of  pain.  Sclerosis  of  the  coronary  arteries 


8  GENERALIZED    PAIN 

causes  pain  in  successive  attacks,  whilst  the 
other  affections  mentioned  above  produce  a  more 
or  less  enduring  pain  of  varying  degree  and 
recurrent  after  bodily  motion  or  exertion.  Many 
patients  who  complain  about  recurrent  pains  in 
a  certain  localized  point  of  the  cardiac  region 
will  be  found  to  have  suffered  a  short  time  ago 
from  an  attack  of  pericarditis.  In  such  cases  I 
have  ventured  upon  a  diagnosis  of  localized 
pericarditic  adhesion.  Whether  I  was  right  I 
will  not  presume  to  say.  But  I  know  for  a 
certainty  that  in  other  cases  of  definite  (proved 
by  post  mortem)  such  like  adhesions  no  traces 
of  pain  could  be  established.  It  is  also  certain 
that  contractures  of  the  pericardium  with  the 
diaphragm  may  be  responsible  for  palpitation, 
dyspnea,  and  sudden  stabbing  pains  in  the  car- 
diac region  frequently  accentuated  by  increased 
diaphragmatic  excursions  (deep  breathing, 
sneezing,  coughing,  when  ascending  stairs). 
The  diagnosis  must  lean  on  the  anamnesis  (pre- 
vious pleuritis,  inflammatory  pleural  affection 
in  the  subphrenic  cavity,  especially  on  the  left 
side),  and  eventually  on  the  Roentgenogram. 
Analogous  manifestations  may  be  provoked  by 
contractures  of  the  diaphragm  with  parietal 
pleura  (pleuritis  adhesiva). 

In  enteroptosis,  particularly  after  cardiopto- 
sis,  we  hear  complaints  about  heart  pain,  palpi- 
tation, anguish,  chiefly  when  in  left  situ  owing 


HEART  9 

to  increased  displacement  of  the  heart.  Similar 
painful  sensations  are  experienced  in  every  other 
abnormal  lateral  displacement  of  the  heart,  in 
sclerosis  of  the  aorta,  cachexia,  neurasthenia, 
but  in  the  latter  also  without  abnormal  lateral 
displacement  because  neurasthenics  ars  as  a  rule 
supersensitive ;  likewise  in  many  other  diseases 
of  the  heart,  even  by  persons  in  apparently  good 
health,  probably  when  extraordinary  demands 
are  made  on  the  cardiac  organs,  when  the  heart 
is  pushed  against  the  thoracic  wall,  and  when 
the  diaphragm  is  raised  above  its  normal  level 
by  any  cause  whatever  in  the  healthy  as  well  as 
in  the  afflicted.  Palpitation,  oppression,  anguish 
are  the  usual  accompanying  symptoms. 

Arteriosclerosis  is  associated  with  pain  in  the 
region  of  the  heart  because  it  increases  cardiac 
labor  and  raises  the  blood  pressure.  Of  greater 
moment  still  seems  to  me  the  fact  that  these 
self-same  pains  with  palpitation,  early  fatigue, 
headache,  and  dizziness  are  often  enough  experi- 
enced in  the  presclerotic  stadium,  and  that  at  a 
time  when  we  find  a  more  or  less  distinct  ac- 
centuation of  the  second  aorta  tonus  with  a 
ringing  sound  and  of  a  vacillating  intensity, 
likewise  a  moderate  rise  in  the  blood  pressure 
subject  to  constant  changes,  and  eventually  a 
slightly  elevated  apex  beat.  All  these  mani- 
festations may  completely,  or  at  any  rate  par- 
tially, disappear  after  a  few  months  when  the 


10  GENERALIZED   PAIN 

causating  factors  (bodily  overexertion,  pre-emi- 
nently mental  excitement,  also  chronic  nicotin- 
ism) have  been  eliminated. 

Retrosternal  pains,  chiefly  above  or  behind 
the  sternum,  deserve  special  mention.  They 
manifest  themselves  in  the  sense  of  oppression, 
pressure,  constant  or  convulsive  sensations,  at 
times  coupled  with  irradiation  towards  both  sides 
of  the  chest  or  of  the  shoulders,  rarely  in  the 
left  arm  under  bodily  exertion  or  mental  ex- 
citement, caused  by  sclerosis  or  lues  of  the  aorta 
(aortalgia). 

They  approximate  anginoid  pains  with  this 
difference,  that  they  are  devoid  of  the  feeling  of 
anguish  and  the  fear  of  a  recurrence  of  the 
trouble,  that  they  radiate  chiefly  into  the  arms, 
preferably  the  left  one,  and  assume  the  form  of 
spontaneous  attacks.  But  they  frequently  lead  to 
anginoid  or  anginose  attacks,  because  their  basic 
affection  of  the  aortic  wall  easily  leads  to  a 
contraction  or  distortion  of  the  ostia  of  the  coro- 
nary arteries,  or  similar  diseases.  A  distinguish- 
ing feature  of  these  "aortal"  pains  may  be  found 
in  their  rapid  disappearance  upon  the  removal 
of  the  causative  element  (exertion,  excitement). 
What  they  have  in  common  with  angina  pectoris 
is  Head's  cutaneous  hyperesthesia  of  the  chest 
and  the  left  arm.  As  in  genuine  angina  pectoris, 
so  here  also  moderate  exercise  in  the  open  air— 


HEART  11 

but  not  in  a  closed  room — will  banish  the  pain 
promptly. 

Continuous  pains  in  the  cardiac  region  may 
be  due  to  affections  which  superinduce  spatial 
contractions  of  the  heart  from  without.  The 
patient  complains  of  pressure,  oppression  and  at 
times  of  moderately  intensive  pain  in  the  region 
of  the  heart.  There  we  are  confronted  by  three 
possibilities:  (1)  the  formation  of  solid  masses 
in  the  anterior  mediastinum  (neoplasms,  cysts, 
gummata  or  any  kind  of  inflammatory  process). 
The  same  may  happen  in  the  posterior  sternum. 
(2)  Mediastinal  pleuritis  (diagnosis  in  detail  is 
given  elsewhere).  (3)  An  accumulation  of  gas 
in  the  cellular  tissue  of  the  posterior  mediasti- 
num, the  sequel  of  an  interstitial  emphysema 
which  is  easily  recognized  by  a  tympanitic  (ab- 
normally sonorous  and  deep)  percussion  sound 
in  compensation  of  heart-dulness,  or  in  other 
words  by  a  deficient  apex  beat,  dulness  of  the 
heart  sounds  despite  an  otherwise  regular  pulse 
rhythm,  even  without  taking  into  consideration 
the  symptoms  of  an  interstitial  emphysema  over 
the  lungs,  in  the  clavicle  and  the  supraclavicular 
fossa.  But  then  every  subdiaphragmatic  disease 
which  produces  an  elevation  of  the  diaphragm 
either  on  both  sides  or  on  the  left  side  only  will 
also  cause  a  spatial  contraction  in  the  region  of 
the  heart.  I  remind  the  reader  here  of  abnormal 
accumulations  of  gas  in  the  stomach  or  in  the 


12  GENERALIZED   PAIN 

intestinal  canal  corresponding  with  a  flexura 
coli  lienalis,  conditions  which,  indeed,  often 
enough,  give  rise  to  the  afore-mentioned  sub- 
jective disturbances.  Yet  it  strikes  me  that 
this  diagnosis  is  often  made  rashly  at  the  bed- 
side only  to  make  room  soon  afterwards  for  a 
recognition  of  a  lethal  sclerosis  of  the  coronary 
arteries. 

Hernia  and  diaphragmatic  eventration  may 
also  show  the  same  effects.  (See  chapter  on 
"Pain  in  the  Chest.") 

Aneurysms  of  the  aorta  claim  here  especial 
attention  even  though  arrosion  of  the  anterior 
bony  thoracic  wall  should  not  as  yet  be  in  evi- 
dence. Now  to  the  left,  or  to  the  right,  side  of 
and  also  behind  the  sternum  a  dull,  at  times  also 
violent,  continuous  "hammering"  pain  will  be- 
come noticeable.  It  is  more  or  less  frequently 
interrupted  by  painful  paroxysms  of  an  inten- 
sive character  making  excursions  into  one 
(right)  or  both  arms,  or  in  the  shoulders,  or  in 
the  back,  either  of  spontaneous  origin  or  due 
(chiefly)  to  bodily  exertion. 

In  aneurysms  of  the  pectoral  aorta  the  pa- 
tient does  not  so  much  complain  of  pain,  but 
rather  of  a  bothersome  sensation  of  coldness  in 
the  cardiac  region. 

Aneurysms  of  the  innominate  artery  will 
cause  the  same  kind  of  pains  which  radiate  into 
the  right  arm  or  to  the  right  shoulder. 


HEART  13 

The  diagnosis  should  be  guided  in  these  cases 
by  the  fierce  intensity  of  the  irradiating  pains, 
the  abnormal  smallness  of  the  pulse  in  the  arte- 
ries of  the  right  arm  and  of  the  right  carotid, 
eventually  also  by  paresis  resp,  paralysis  of 
the  right  recurrent  nerve,  acceleration  of  the 
pulse  in  the  right  carotid  and  the  subclavia  (and 
their  branches)  only,  and  by  the  Roentgeno- 
gram.  Pulsation  behind  the  right  sternoclavicu- 
lar  articulation  or  immediately  above  or  below 
it,  a  dulness  above  it  or  a  pulsating  protuber- 
ance or  tumor  may  not  yet  be  noticeable  in  the 
earlier  stages. 

Another  source  of  pain  may  be  found  in  the 
irritation  (no  matter  what  its  origin  may  be, 
neuralgia,  neuritis)  of  the  left  phrenic  nerve, 
f.i.,  due  to  diaphragmatic  pleuritis,  imagination 
of  the  pleural  membrane,  compression  of  the 
mediastinal  glands,  etc.  The  typical  pressure 
points,  eventually  singultus  and  a  conspicuous 
bradypnea  lead  the  way  to  a  proper  diagnosis. 

Piercing  or  pulling  pain  in  the  region  of  the 
heart  (often  radiating  into  the  back)  is  a  regular 
companion  of  tetanic  convulsions,  at  any  rate 
when  they  are  of  a  pronounced  character.  Te- 
tanic contractions  are  here  the  probable  under- 
lying cause. 

Persons  suffering  from  poisoning  with  per- 
chloride  of  mercury  often  complain  of  severe, 
continuous  pains  in  the  heart  region.  Stomatitis 


14  GENERALIZED  PAIN 

and  mercurial  enteritis  coupled  with  intense 
pains  in  the  extremities  give  expression  to  this 
toxic  neuromyositis.  A  patient  of  mine  who 
was  so  afflicted  died,  and  the  post  mortem  re- 
vealed a  high  grade  degeneration  of  the  muscu- 
lature of  the  heart. 

A  dull  pain  in  the  heart  will  often  constitute 
the  most  prominent,  if  not  the  only,  symptom 
of  chronic  tobacco  heart.  Anamnesis  should  here 
be  decisive. 

In  the  aforementioned  ailments  we  can  speak 
principally  of  continuous  pains  in  the  cardiac 
region,  but  in  sclerosis  or  syphilis  of  the  coronary 
arteries  (aorta)  they  assume  the  character  of 
intermittent  attacks  due  either  to  bodily  exercise 
or  mental  excitement,  or  also  to  spontaneous 
causes.  In  their  milder  form  they  are  known 
as  anginoid  attacks.  The  diagnosis  will  rest  on 
the  sensation  of  oppression  and  anguish  which 
accompanies  the  pain. 

The  kind  of  painful  sensation  experienced  by 
the  patient  should  strongly  appeal  to  the  medi- 
tation of  the  diagnostician.  The  patient  says 
that  he  feels  a  tense  pressure  back  of  the  ster- 
num, or  a  pressing,  burning  pain,  a  feeling  as 
if  a  specially  hot  or  rather  large  morsel  of  food 
had  slipped  down  the  esophagus.  If  we  find 
this  in  company  with  a  well-pronounced  sensa- 
tion of  anguish,  we  are  pretty  safe  in  deciding 
on  an  arteriosclerosis  of  the  heart  or  of  the 


HEART  15 

aorta  or  of  the  peripheral  vessels.  But  if  in 
the  absence  of  anguish  we  are  dealing  with  pains 
of  a  milder  nature,  the  suggestion  of  neuritis  or 
hysteria  lies  closer.  Angina  pectoris  is  not  al- 
ways associated  with  very  intense  pains.  (See 
section  dealing  with  "Angina  Pectoris.") 

Localization  of  the  pains  is  here  the  important 
factor  for  the  differential  diagnosis.  As  a  rule 
they  point  rather  in  the  direction  back  of  the 
sternum,  not  to  the  region  of  the  heart,  as  is  the 
case  in  typical  angina  pectoris.  In  other  cases 
the  dragging  pain  is  not  located  in  the  median 
line  behind  the  sternum,  but  on  the  outer  edge 
of  the  superior  sternum,  mainly  to  the  left,  some- 
times travelling  to  the  shoulder  and  the  arm. 

The  neurotic,  hysterical,  anginoid  heart  pain 
seeks  with  predilection  the  region  of  the  apex, 
frequently  somewhat  without  and  below  it,  or 
the  2.  or  4.  left  intercostal  space.  It  flares  up 
under  pressure  of  the  finger  unless  the  focus  of 
the  pain  is  centered  in  the  nipple  (hyperesthetic 
point).  It  would  be  a  mistake  to  reduce  this 
kind  of  pain  to  a  functional  disorder  of  the 
heart,  especially  so  if  we  take  into  consideration 
that  nervous  concomitant  manifestations  are  not 
infrequently  associated  with  anatomical  impair- 
ment of  the  circulatory  apparatus. 

Sensations  of  anguish  and  oppression  in  the 
region  of  the  heart  occurring  chiefly  in  the  night 
time  (over-early  awakening),  sometimes  also  in 


16  GENERALIZED   PAIN 

the  daytime,  even  continuous,  point  rather  to 
an  inferior  form  of  angina  pectoris  (anginoid 
conditions).  But  they  may  also  constitute  (even 
if  only  in  exceptional  cases)  symptoms  of  a 
cerebral  arteriosclerosis.  We  must  consider  here 
the  age  of  the  patient  (beyond  the  40th  year) 
and  the  other  symptoms  of  cerebral  arterio- 
sclerosis, viz.,  headache,  vertigo,  combined  with 
nausea  or  vomiting,  impairment  of  memory,  es- 
pecially for  events  of  a  recent  date,  changes  of 
character  such  as  abnormal  irritability,  depress- 
ing moods,  intolerance  of  alcohol,  etc. 

In  the  differential  diagnosis  we  encounter 
here  a  difficult  question.  Do  anginoid  condi- 
tions in  the  sense  of  painful  attacks  in  the 
cardiac  region  coupled  with  sensations  of  an- 
guish point  to  an  incipient  arteriosclerosis,  or  are 
they  a  symptom  of  climacteric  neurosis?  We 
meet  them  in  both  instances.  The  answer  will 
be  found  in  the  proper  consideration  of  the  other 
classical  signs  of  the  latter,  viz.,  congestion,  par- 
esthesia,  attacks  of  tachycardia,  Heberdens  no- 
dules, accumulation  of  adipose  tissue,  absence  of 
motoric  pain,  but  improvement  under  bodily 
exercise,  success  or  failure  of  therapeutic  meas- 
ures (nitroglycerin,  erythrotetranitrate  show  no 
results). 

Basedow's  disease  (hyperthyreoidism)  is  also 
accompanied  by  anginoid  attacks.  Diagnosis  is 
assisted  here  by  the  findings  of  cardinal  symp- 


HEAET  17 

toms  of  this  disease,  struma,  exophthalmos, 
tachycardia,  tremor,  abnormally  increased  meta- 
bolism, i.e.,  progressive  emaciation  in  spite  of 
abundant  food  consumption. 

Paroxysmal  tachycardia  may  also  evince  an- 
ginoid  attacks  coupled  at  times  even  with  an- 
ginose  pains,  owing  to  ischemia  of  the  cardiac 
muscles. 

In  some  cases  of  psychopathia  of  a  depressive 
character  which  has  so  many  points  in  common 
with  neurasthenia,  e.g.,  melancholia,  anginoid 
troubles  may  also  appear,  especially  in  the  sense 
of  precordial  anguish.  An  analysis  of  the  psy- 
chic, likewise  of  the  somatic,  condition  of  the 
patient  sustains  the  diagnosis 

In  epilepsy  these  anginoid  attacks  bear  a 
double  significance.  They  serve  as  a  sensible 
aura  which  is  easily  recognized  because  the  sub- 
sequent epileptic  attacks  sharply  clear  up  the 
situation.  On  the  other  hand,  they  represent  an 
epileptic  equivalent:  pre-  and  post-existence  of 
typical  convulsions  furnish  the  proof.  In  cases 
devoid  of  these  attacks  the  diagnosis  is  rather 
difficult.  As  leading  points  may  be  mentioned: 
youthfulness  of  the  patient,  consciousness  tem- 
porarily clouded  during  the  attacks,  unusual  ac- 
companying symptoms,  complete  physical  ability 
of  subject  during  the  free  intervals  in  contra- 
distinction to  psychical  changes  in  the  inter- 
paroxysmal  stadium. 


18  GENERALIZED    PAIN 

Anginoid  conditions  often  serve  as  concomi- 
tant symptoms  in  the  following  diseases:  the 
so-called  anatomical  or  functional  affections  of 
the  heart,  acute  peri-  or  myocarditis,  acute  over- 
straining of  the  heart,  chronic  syphilitic  myocar- 
ditis, defects  in  cardiac  stimulation,  in  general 
in  every  initial  myocardial  weakness,  especially 
in  the  dropping  heart,  mitral  heart,  myocardial 
tuberculosis,  or  in  chronic  pulmonary  affections, 
contraction  of  the  heart  with  the  pericardium, 
arteriosclerosis,  syphilis  and  aneurysm  of  the 
aorta,  and  also  in  kyphoscoliosis.  Irregularity, 
retardation  or  acceleration  of  the  heart  beats, 
dulness  of  sound,  etc.,  will  complete  the  diagno- 
sis. Often  when  special  demands  are  made  on 
the  heart's  action,  for  instance,  in  exceptional 
cases  of  sudden  increase  in  the  blood  pressure 
(vesicular  crises)  we  may  hear  of  complaints 
about  pressure,  pain  and  oppression  in  the  re- 
gion of  the  heart,  extending  to  the  nape  of  the 
neck,  by  choice  in  the  left  arm. 

In  insufficiency  of  the  left  ventricle,  nephritis, 
arteriosclerosis  and  chronic  myocarditis,  these  an- 
ginoids  come  to  the  foreground  in  the  shape  of 
sensations  of  anguish  and  dyspnea,  culminating 
eventually  in  severe  attacks  of  cardiac  asthma. 
They  rarely  fail  to  make  their  appearance  in 
essential  arterial,  hypertension. 

Sometimes  they  follow  in  the  wake  of  pilocar- 
pin  injections,  presumably  by  effects  on  the 


HEART  19 

vagus  branches  of  the  coronary  artery.  They 
are  generally  found  also  as  partial  symptoms  in 
vagotony. 

At  times  it  will  be  necessary  to  decide  whether 
we  are  dealing  with  a  bronchial  pain  in  an  ar- 
teriosclerotic  patient  or  an  anginoid  condition 
due  to  sclerosis  of  the  aorta. 

Anginoid  pains,  even  anginose  attacks,  are 
often  coupled  with  other  cardiac  affections,  such 
as  palpitation  (cf.  under  that  heading),  skipping 
pulse,  precordial  anguish,  oppression  due  to  a 
postcecal  pneumatosis  of  the  stomach,  or  to 
swallowing  air  or  to  abnormal  gas  formation  in 
the  canal.  These  processes,  no  doubt,  are  gen- 
erally formed  in  nervous  people,  whose  heart 
action  as  a  rule  is  quite  faultless,  yet  they  al- 
ways give  rise  to  doubts  about  arteriosclerosis 
or  adiposity  being  present.  I  can  never  shake 
off  these  doubts  until  I  find  definite  proof  of 
an  unmistakable  elevation  of  the  diaphragm, 
succeed  in  removing  the  pain  by  evacuation  of 
the  gas,  and  am  convinced  that  motoric  dyspnea 
is  not  present. 

If  the  elevation  of  the  diaphragm  is  due  to  a 
direct  attack  on  the  diaphragmatic  muscles,  or 
to  a  lesion  of  the  phrenic  nerve,  or  if  a  basal 
adhesive  pleuritis  has  impaired  the  motility  of 
the  diaphragm,  the  diagnosis  will  be  much  easier. 
The  clinical  and  radiologic  examinations  are  the 
directing  guides. 


20  GENERALIZED   PAIN 

Anginoid  conditions  in  the  sense  of  pains  in 
the  region  of  the  heart,  sensations  of  anguish, 
palpitation,  shortness  of  breath,  may  also  point 
to  a  dry  pleuritis  in  the  precordial  region.  More 
about  this  anon. 

A  final  diagnosis  may  meet  with  almost  in- 
superable difficulties  in  the  following  conditions: 
fatty  degeneration  of  the  heart,  in  the  beery 
heart,  sclerosis  of  the  coronary  arteries.  Do  the 
anginoid  conditions  point  to  these  affections  or 
to  primary  myocardiac  troubles?  In  how  far 
and  how  often  does  nicotinism  play  here  a  role? 
Does  the  bedside  examination  reveal  these  con- 
ditions? 

If  we  deal  with  a  very  sudden  and  highly  in- 
tensive pain  in  the  cardiac  region  we  may  be 
pretty  sure  that  we  are  confronted  by  an  ana- 
tomical disorder  of  the  heart  or  its  larger  vessels 
or  of  other  organs  located  close  by,  or  also  some 
distance  removed  from  the  heart  itself.  Func- 
tional disease  is  in  such  cases  rather  remote. 
Particulars  about  this  will  be  found  under  "An- 
gina Pectoris." 

Leaving  this  affection  for  the  present  out  of 
consideration,  I  wish  to  say  that  intensive  pains 
in  the  region  of  the  heart  caused  by  acute  dis- 
orders are  proportionately  of  rare  occurrence. 
They  come  under  our  notice  perhaps  more  in 
the  shape  of  an  overstretching  of  the  myocar- 
dium in  cases  of  paroxysmal  tachycardia. 


HEART  21 

Very  sudden,  fiercely  stabbing  pains  point 
to  acute  pericarditis  coupled  with  a  very  pro- 
nounced dyspnea.  The  pericarditis  may  be  the 
result  of  articular  rheumatism  or  some  other 
acute  infection  (sepsis,  pneumonia)  or  it  may 
be  the  forerunner  of  a  rheumatic  fever  (acute) 
or  a  partial  manifestation  of  polyserositis.  A 
diagnosis  of  pericarditis  under  these  conditions 
is  open  to  error.  In  my  earlier  years,  when  I 
was  a  young  assistant,  I  fell  into  this  error. 
It  was  really  a  case  of  pleuro-pericarditis,  i.e., 
pericarditis  externa.  Most  of  these  cases  are 
due  to  some  hemorrhagic  infarct,  but  sometimes 
also  to  pneumonia  in  the  upper  lobe  or  to  an 
independent  pleuritis  mediastinalis  ant.  sin.  A 
careful  study  of  the  friction  fremitus  will  be 
a  decided  adjuvant  in  the  diagnosis. 

These  sudden  pains  do  not  often  make  their 
appearance  in  cases  of  internal  pericarditis,  and 
are  therefore  a  fairly  safe  guide  in  diagnosing 
for  external  pericarditis. 

In  internal  pericarditis  I  have  observed  a  cer- 
tain particular  kind  of  pain:  In  a  case  of  fibrin- 
ous  pericarditis  the  patient  complained  of  an  in- 
tensive, piercing  pain  in  the  cardiac  region  which 
set  in  with  every  heart  beat.  It  was  so  distinct 
that  temporary  irregularities  of  the  heart  action 
were  marked  by  a  simultaneous  arhythmia  of 
the  pain.  In  other  cases — of  rare  occurrence 
so  far  as  my  own  experience  is  concerned — the 


22  GENERALIZED   PAIN 

patient  complains  of  a  violent,  continuous  pain 
in  the  region  of  the  heart,  with  excursions  into 
the  left  shoulder,  of  painful,  superficial  breath- 
ing, often  connected  with  singultus  and  vomit- 
ing. The  cause  for  these  phenomena  may,  per- 
haps, be  found  in  a  prominent  mitral  affection 
of  the  pericardial  branch  of  the  phrenic  nerve 
or  in  the  latter  itself. 

Acute  affections  of  the  aorta  are  apt  to  give 
rise  to  complaints  of  sudden,  at  times  very  in- 
tensive, pains  in  the  region  of  the  heart.  I 
have  seen  only  two  cases  of  acute  infectious 
(not  syphilitic)  aortitis  so  far  in  my  practice 
(more  cases  are  reported  in  French  literature). 
In  one  case  the  patient  complained  of  violent 
continuous  pains  behind  the  superior  sternum, 
with  increasing  demarcation  and  a  ringing  qual- 
ity of  the  second  aorta  tonus.  It  was  a  case  of 
florid  acute  articular  rheumatism.  The  second 
case  was  that  of  a  convalescent  from  abdominal 
typhoid.  The  patient,  otherwise  in  good  health 
and  able  to  do  hard  work,  complained  of  pains 
behind  the  sternum.  When  walking  they  in- 
creased in  violence  and  forced  him  to  stand  still 
for  a  while.  He  had  no  fever,  but  a  protracted 
dicrotia,  strongly  accentuated,  ringing  quality 
of  the  second  aorta  tonus,  especially  in  the  first 
intercostal  space  to  the  right  of  the  sternum. 

Rare  cases  of  aortic  aneurysm,  due  to  acute 
infections  (syphilis,  tuberculosis,  acute  articular 


HEART  23 

rheumatism),  belong  in  this  category.  But  it 
seems  to  me  that  they  develop  rather  on  the 
ground  of  mycotic  embolism  as  spurious  aneu- 
rysms  in  the  wall  of  an  aorta  that  has  already 
deteriorated  through  the  loss  of  the  inner  layer. 
As  a  rule  they  are  recognized  only  when  the 
aneurysm  has  run  its  full  course. 

Sudden  very  violent  pain  in  the  region  of  the 
heart  accompanied  by  oppression,  collapse  and 
vomiting  may  be  the  concomitant  symptom  of 
a  rupture  of  the  heart  with  hemopericardium, 
or  of  the  ventricular  septum  due  to  anemic  ne- 
crosis, or  of  the  rupture  of  a  papillary  muscle, 
or  of  the  aorta  or  of  the  coronary  artery,  or  of 
the  rupture  of  a  cardiac  aneurysm,  or  of  an 
aortic  valve  or  of  an  aortic  valvular  aneurysm, 
or  of  the  rupture  of  a  pulmonary  vein,  the 
bursting  of  an  aortic  aneurysm  into  an  adja- 
cent organ  (pleura,  bronchus,  trachea,  pericar- 
dium, mediastinum,  esophagus),  or  the  bursting 
of  a  bronchial  gland  into  the  aorta  and  thence 
into  the  pericardium,  or  it  may  be  the  sudden 
formation  of  a  dessicating  aneurysm  of  the 
aorta. 

The  kind  of  pain  of  which  the  patient  com- 
plains, viz.,  the  sensation  as  if  something  had 
been  torn  in  twain  within  the  chest,  and  the 
anamnesis  are  strong  hints  of  the  aforementioned 
catastrophe. 

The  diagnosis  of  a  rupture  of  the  heart  or 


24  GENEKALIZED   PAIN 

also  of  a  cardiac  aneurysm  or  of  the  aorta  can 
only  be  confirmed  by  the  finding  of  an  acute 
hemopericardium.  This  would  also  establish  the 
diagnosis  of  the  bursting  of  an  aorta  aneurysm 
if  such  a  diagnosis  was  already  previously  made. 
Rupture  of  the  aorta  leads  to  death  much 
quicker  than  a  rupture  of  the  heart  proper. 

The  diagnosis  of  a  rupture  of  an  aortic  valve 
depends  upon  the  proof  of  an  acute,  i.e.,  sud- 
denly arising,  mostly  incomplete  insufficiency  of 
the  valves  themselves.  In  the  spot  where  an 
aortic  aneurysm  bursts  into  the  mediastinum,  or 
into  the  upper  vena  cava  or  any  other  medias- 
tinal  organ,  a  painful  sensation  will  be  rarely 
found,  and  we  must  look  for  other  accompany- 
ing symptoms  for  our  diagnosis.  But  there  are 
cases  in  which  severe  pains  in  the  chest  with 
vomiting  are  experienced.  The  pain  is  gener- 
ally located  to  the  right  of  the  sternum,  below 
the  right  clavicle. 

In  the  rupture  of  a  papillary  muscle  the 
diagnosis  can  never  be  definitely  established 
intra  vitam;  for  besides  the  sudden,  overwhelm- 
ing pains,  we  find  the  symptoms  of  an  acute 
insufficiency  of  the  heart  which  leads  to  death  in 
a  few  hours  (galoping  rhythm,  embryocardia, 
acute  dilatation  of  the  heart,  absence  of  pulse 
beats,  dizziness,  nausea,  oppression). 

The  diagnosis  of  a  desiccating  aneurysm  of 
the  aorta  can  only  then  be  made  with  approach- 


HEART  25 

ing  certainty  when  we  find  an  aortic  aneurysm 
in  a  patient  who  has  suffered  a  trauma,  but 
previous  to  that  was  hearty  and  showed  no  signs 
of  an  aortic  aneurysm  under  medical  examina- 
tion, a  person  who  never  had  syphilis,  so  that 
the  aneurysm  came  into  evidence,  so  to  speak, 
as  an  acute  process. 

The  stomach  is  frequently  the  source  of  sud- 
den, vehement  pains  in  the  cardiac  region. 
There  may  be  a  perforation  of  a  ventricular 
ulcer  into  the  peritoneal  cavity,  or  an  acute 
peritonitis  emanating  from  the  stomach,  or  a 
volvulus  of  the  stomach  or  a  gastritis.  We 
may  be  quite  sure  that  no  subjective  pains  will 
arise  from  these  conditions  in  the  epigastrium 
or  in  any  other  place  in  the  abdomen,  except 
and  exclusively  in  the  region  of  the  heart.  A 
definite  diagnosis  may  be  made  if  we  have  pre- 
viously already  examined  the  patient,  and  if 
the  anamnesis  has  informed  us  about  the  exist- 
ence of  a  ventricular  ulcer.  Where  this  is  not 
the  case  and  where  we  are  confronted  by  a 
suddenly  arising  volvulus  of  the  stomach,  only 
the  thought  of  the  possibility  of  any  one  of  these 
affections  of  the  stomach,  together  with  a  local 
examination,  can  lead  to  a  resulting  diagnosis, 
and  even  then  the  consideration  of  an  angina 
pectoris  may  offer  complicating  difficulties.  This 
latter  point  craves  serious  thought,  because  in 


26  GENERALIZED  PAIN 

many  affections  of  the  stomach  the  existing 
pains  are  accompanied  by  sensations  of  anxiety. 

Destructive  affections  of  the  gastric  parietes, 
foremost  a  ventricular  carcinoma  or  ulcer,  may 
create  sudden,  most  incisive  pains  in  the  region 
of  the  heart,  especially  when  they  burst  into  the 
pericardium.  The  acute  formation  of  a  hemo- 
or  hemopneumo-pericardium,  aided  by  the  pre- 
ceding anamnesis  and  clinical  examination,  will 
facilitate  the  diagnosis. 

The  sensation  of  anguish,  principally  the  so- 
called  precordial  anguish,  i.e.,  oppression  and 
constriction  in  the  cardiac  region  and  behind  the 
sternum,  often  coupled  with  a  choking  sensation 
in  the  throat  culminating  in  real  death  agony, 
constitutes  one  of  the  characteristic  signs  of 
angina  pectoris  (stenocardia).  There  are  cases 
in  which  the  sensation  of  anguish  and  oppression 
in  the  chest  is  of  such  a  high  degree  of  intensity, 
yet  without  pain,  that  the  patient  collapses  and 
death  intervenes.  But  in  the  majority  of  cases 
we  come  across  a  whole  list  of  valuable  symp- 
toms: pain  behind  the  median  sternum  following 
the  line  of  the  heart,  radiation  into  the  left  arm, 
especially  on  the  side  of  the  little  finger,  like- 
wise in  the  left  side  of  the  nape  of  the  neck 
itself,  and  also  of  the  face,  not  always  very 
intense  in  its  nature  but  rather  secondary  to  the 
sensation  of  anguish  which  becomes  well  nigh 
unbearable;  besides  these  there  is  pallor,  the 


HEART  27 

Hyppocratic  fades,  clammy  cold  sweat,  absolute 
rigidity  of  the  body  (the  patient  stands  stock- 
still,  or  if  the  attack  comes  in  the  nighttime  he 
sits  up  rigidly  and  immovable  on  the  edge  of 
the  bed),  avoidance  and  fear  of  deep  breathing 
(in  some  cases,  on  the  contrary,  deep  respira- 
tion brings  relief),  accelerated,  but  sometimes 
retarded,  heart  beats,  overmastering  the  attack 
by  a  special  physical  effort,  sometimes  by  ab- 
dominal straining  during  defecation,  passage  of 
gas  either  through  the  mouth  or  per  rectum. 
Who  has  not  observed  these  signs  in  his  bedside 
practice? 

With  the  whole  complex  of  these  symptoms 
before  us,  the  diagnosis  cannot  go  amiss.  But 
I  wish  to  lay  stress  on  the  fact  that  in  spite  of 
these  symptoms  angina  pectoris  is  at  times  by 
mistake  diagnosed  as  an  affection  of  the  stom- 
ach with  gastralgia,  because  the  attack  may 
yield  either  spontaneously  or  through  the  means 
of  a  small  dose  of  bicarbonate  of  soda  to  a 
sudden  act  of  belching  or  eructation. 

If  a  stenocardia  has  been  correctly  diagnosed, 
then  we  must  inquire  into  the  last  cause  of  the 
attack:  an  acute,  or  an  acute  infectious,  peri- 
carditis, or  a  chronic  myocarditis  may  bring 
about  anginose  attacks,  or  a  concretion  between 
heart  and  pericardium,  or  a  stenosis  of  the  aortic 
or  mitral  ostium,  an  embolism  or  thrombosis  of 
the  coronary  artery,  or  chronic  nicotinism  may 


28  GENERALIZED   PAIN 

be  at  the  bottom  of  these  attacks.  Tabetic  heart 
crises  or  purely  hysterical  or  vasomotoric  con- 
ditions may  evince  them.  But  the  most  fre- 
quent cause  will  be  found  in  a  sclerosis  of  the 
ascending  portion  of  the  thoracic  aorta  where 
the  coronary  arteries  branch  off,  or  in  a  sclerosis 
of  these  arteries  themselves,  i.e.,  endaortitis  or 
endarteritis  of  syphilitic  origin. 

Due  consideration  of  age  and  anamnesis  will 
in  all  probability  decide  between  syphilitic  endar- 
teritis, resp.  endaortitis  and  arteriosclerosis  as 
underlying  cause.  Age  below  forty  years  points 
to  syphilitic  endarteritis.  But  it  is  not  an  in- 
fallible sign,  for  our  present  knowledge  teaches 
us  that  arteriosclerosis  may  also  occur  before 
the  fortieth  year  is  reached;  in  fact,  at  almost 
any  time  of  life.  Neither  is  the  anamnesis  a 
definitely  deciding  factor,  even  in  conjunction 
with  other  coexisting  metaluetic  diseases,  chiefly 
of  the  central  nervous  system  (tabes,  taboparal- 
ysis,  cerebrospinal  syphilis),  because  we  should 
bear  in  mind  that  arteriosclerosis  has  a  basic 
predilection  for  syphilitic  affections. 

The  Wassermann  reaction,  although  of  great 
significance,  is  not  always  an  absolutely  reliable 
indication.  It  is  true  that  in  most  cases  this 
disease  points  to  syphilitic  influences.  But  I  am 
not  fully  convinced  that  it  may  not  be  connected 
also  with  a  true  arteriosclerosis  of  the  aorta  or 
of  the  coronary  arteries,  and  that,  after  all,  an- 


HEART  29 

gina  pectoris  may  be  the  exciting  factor  of  this 
disease.  In  such  cases  of  doubt  we  can  only 
find  assistance  in  the  resulting  efficacy  of  anti- 
syphilitic  treatment. 

Whether  embolism  of  a  coronary  artery  is  the 
cause  of  anginose  affections  can  be  easily  de- 
cided when  the  existence  of  an  endocarditis  of 
the  aortic  valves  has  been  definitely  established 
and  when  the  patient,  mainly  of  youthful  age, 
quickly  succumbs  under  the  anginose  attack. 
On  the  other  hand,  when  the  embolism  originates 
from  an  atheromatous  ulcer  at  the  root  of  the 
aorta,  the  etiological  diagnosis  of  the  lethal  an- 
ginose attack  will  have  no  higher  value  than  in 
cases  where  a  thrombosis  in  one  (chiefly  the 
left)  coronary  artery  was  the  basic  cause.  When 
the  outcome  is  not  fatal  a  differential  diagnosis 
of  an  angina  pectoris  on  the  basis  of  an  arterio- 
sclerosis in  one  of  the  coronary  arteries  at  the 
time  of  the  attack  seems  to  me  impossible.  The 
following  conditions  may  point  to  thrombosis 
as  the  exciting  cause :  unusually  prolonged  pains, 
high  degree  of  cardiac  weakness,  quick  but  thin 
pulse,  embryocardia,  emaciated  appearance,  im- 
paired diuresis,  faint  heart  beats,  splitting  of  the 
first  apex  beat,  acute  dilatation  of  the  heart  and 
acute  vascular  congestion. 

If  later  on  a  partial  cardiac  aneurysm  is  rec- 
ognized, the  diagnosis  of  an  acute  thrombotic 
or  embolic  occlusion  of  one  of  the  branches  of 


30  GENEBALIZED   PAIN 

the  coronary  artery  may  be  regarded  as  cer- 
tain. Furthermore,  when  a  sudden  anginose 
attack  is  immediately  followed  by  a  feverish,  at 
times  only  fibrinose,  but  also  exudative  pericar- 
ditis— in  some  cases  this  manifests  itself  during 
the  first  two  or  four  days  as  a  continuous  sensa- 
tion of  pain  or  oppression  in  the  region  of  the 
heart — it  may  be  an  indicator  of  an  acute  oc- 
clusion of  a  coronary  artery  branch  with  a  sub- 
sequent necrotic  infarct  and  the  final  formation 
of  a  partial  chronic  cardiac  aneurysm.  Such 
cases  are  by  no  means  rare.  But  the  diagnosis 
is  infallible.  I  remember  just  such  a  case.  The 
patient  succumbed  rapidly.  The  post  mortem 
did  not  show  an  "epistenocardiac  pericarditis," 
but  a  very  pronounced  sclerosis  of  the  ascending 
aorta  and  its  arch,  with  a  number  of  atheroma- 
tous  ulcers,  one  of  which  had  burst  through  the 
wall  of  the  aorta.  This  produced  a  periaortitis 
at  the  root  of  the  aorta,  followed  by  acute  peri- 
carditis. The  anginose  attacks  were  due  to  well- 
marked  changes  in  the  switch  of  the  coronary 
artery.  No  traces  of  a  sclerosis  or  occlusion 
in  the  coronary  artery  or  in  its  branches  could 
be  discovered.  Myomalacia  of  the  heart  was 
absent. 

Some  authors  claim  that  an  acute  infectious 
aortitis  may  give  rise  to  typical  attacks  of  an- 
gina pectoris,  but  I  have  never  seen  such  a  case. 

In  recurrent  attacks  of  angina  pectoris,  espe- 


HEAET  31 

cially  when  the  anginose  pains  with  irradiation 
continue  for  several  days,  i.e.,  when  a  status 
anginosus  exists,  it  is  well  to  think  of  an  acute 
pericarditis  as  the  hearth  from  which  the  trouble 
proceeds.  It  is  claimed  that  even  a  dry  pleuritis 
in  the  precordium  will  induce  typical  anginose 
pains,  i.e.,  pains  in  the  region  of  the  heart  with 
excursions  into  the  left  arm,  sensation  of  fear, 
palpitation,  excited  heart  action  and  dyspnea. 
I  have  never  had  the  privilege  of  seeing  such  a 
case,  although  I  have  treated  quite  a  number 
of  cases  of  extrapericardiac  pleuritis  with  pains 
in  the  region  of  the  heart. 

The  problem  offers  greater  difficulties  when 
angina  pectoris  is  based  upon  a  concretion  be- 
tween the  heart  and  pericardium.  In  this  con- 
dition the  coronary  arteries  are  held  in  a  vicelike 
embrace,  the  circulation  is  impeded  and  anginose 
pains  are  the  result. 

But  such  a  diagnosis  can  only  be  established 
when  absolutely  unmistakable  symptoms  of  a 
concretion  are  found. 

In  stenosis  of  the  aortic  or  mitral  ostium  we 
may  observe  angina  pectoris  either  in  a  well 
pronounced  form,  or  in  the  shape  of  a  mitigated 
anginoid  condition,  probably  as  a  symptom  of 
an  insufficient  blood  supply  in  the  myocardium 
by  increased  activity.  The  diagnosis  must  rest 
upon  the  finding  of  the  exciting  cause.  But  we 
must  not  overlook  the  fact  that  painful  attacks 


32  GENERALIZED  PAIN 

similar  to  a  coronary  angina  in  mitral  stenosis 
may  also  be  the  sequel  of  a  consecutive  sclerosis 
of  the  pulmonary  artery.  I  shall  revert  to  this 
later  on. 

Anginose  attacks  will  also  crop  up  in  chronic 
inflammatory  or  degenerating  diseases  of  the 
myocardium  without  affections  of  the  coronary 
artery.  To  distinguish  these  rare  cases  from 
true  sclerosis  of  the  coronary  arteries  even  with 
approaching  certainty  intra  vitam  seems  to  me 
impossible. 

Chronic  nicotine  poisoning  should  be  sus- 
pected in  all  patients,  especially  in  females,  who 
present  one  or  more  anginose  attacks.  We 
should  be  guided  here  by  the  other  coexistent 
symptoms :  palpitation,  tachycardia,  arythmia,  es- 
pecially in  the  sense  of  extrasystolic  conditions, 
cold  sweats,  tremor  during  the  attack,  retro- 
bulbar  neuritis,  dyspeptic  troubles,  intermittent 
distension  of  the  thyroid  glands,  nocturnal 
palpitation  of  the  heart.  And  yet  all  these 
symptoms  may  not  constitute  a  definite  proof 
for  the  toxic  genesis  of  the  anginose  attacks  and 
for  a  good  prognosis.  Nicotinism  is  a  predis- 
posing factor  in  arteriosclerosis,  particularly 
in  the  coronary  arteries.  A  genuine  angina 
coronaria  may  already  exist  and  the  first  visible 
attack  may  be  lethal  although  the  patient  has 
experienced  no  previous  inconvenience. 

On   the   other   hand   let   us    remember    that 


HEABT  33 

stenocardia  in  an  inveterate  smoker  may  also  be 
due  to  sclerosis  or  syphilis  of  the  coronary 
arteries  not  necessarily  connected  with  anginose 
attacks,  but  that  the  vascular  cramps  may  be 
superinduced  by  the  immoderate  use  of  tobacco. 
If  abstinence  from  smoking  restores  the  heart 
to  normal  activity  we  have  a  definite  proof  of 
the  toxic  origin  of  the  anginose  attacks. 

In  rare  cases  of  excessive  use  of  coffee  and 
tea  anginose  attacks  will  appear.  Palpitation 
of  the  heart,  tremor,  and  vasomotoric  symptoms 
differentiate  them  from  genuine  angina  pectoris. 
Even  if  these  attacks  are  accompanied  by  brady- 
cardia,  the  diagnosis  for  the  aforesaid  etiology  is 
contraindicated.  A  true  angina  pectoris  exists 
combined,  like  all  other  toxic  anginas,  with  tachy- 
cardia of  a  moderate  degree,  but  in  the  severest 
cases  with  bradycardia. 

Among  the  toxic  anginas  we  must  count  the 
rare  cases  of  anginose,  or  in  most  instances  angi- 
noid  manifestations  arising  from  chronic  morphin- 
ism or  caused  by  inhalation  of  COz,  e.g.,  after 
carbonic  acid  baths  or  by  tuberculin  injections. 
The  diagnosis  is  governed  by  the  anamnesis. 

Toxic  forms  of  stenocardia  are  also  found  by 
some  authors  in  lead  poisoning,  in  gout  and  in 
diabetes  meUitus.  I  will  not  deny  that  such 
toxic  stenocardias  exist  in  gout,  for  instance,  as 
vicarious  attacks  of  an  articular  nature.  But 
so  far  as  my  own  clinical  experience  goes,  I 


34  GENERALIZED   PAIN 

speak  with  the  utmost  reserve.  I  remember  two 
cases  of  gout — one  a  man,  thirty-six  years  of 
age — in  which  I  observed  typical  anginose  at- 
tacks. In  the  heart  and  vessels  I  could  find 
nothing  abnormal.  These  conditions  misled  me 
into  a  diagnosis  of  gouty,  i.e.,  toxic  angina 
pectoris.  But  both  patients  soon  succumbed  to 
a  renewed  attack  of  stenocardia.  Clear  cases 
of  sclerosis  of  the  coronary  arteries.  In  a  third 
case,  I  insisted  on  a  diagnosis  of  angina  coro- 
naria.  Three  of  my  colleagues  stuck  to  uratic 
angina  pectoris.  The  patient  died  of  a  classical 
anginose  attack  in  a  tepid  bath. 

In  tabes  dor  sails  syphilis  of  the  aorta  or  of 
the  coronary  arteries  may  bring  about  anginose 
attacks.  Insufficiency  of  the  aortic  valves  goes 
together  with  tabes  also.  This  last  named  com- 
bination alone  is  often  an  indication  that  the 
tabetic  condition  originates  at  the  point  of  divi- 
sion between  the  coronary  artery  and  the  aorta 
which  latter  is  either  affected  by  syphilis  or 
arteriosclerosis.  But  this  is  a  mere  opinion, 
because  true  angina  pectoris  is  of  rare  occur- 
rence despite  the  frequency  of  insufficiency  of 
the  aorta  in  tabes. 

On  the  other  hand  there  are  cases  of  tabes 
dorsalis  in  which  the  anginose  attacks  assume 
the  full  meaning  of  tabetic  crises.  The  existing 
causes,  no  doubt,  will  assist  in  distinguishing 
between  these  two  subdivisions. 


HEART  35 

The  true  stenocardiac  attack  arising  from  an 
affection  of  the  coronary  arteries  is  primarily 
superinduced  by  some  physical  exertion  (run- 
ning for  instance  after  a  train  or  street  car, 
mounting  steps,  or  a  brisk  walk  after  a  heavy 
meal)  or  by  a  sudden  change  in  the  temperature 
(going  from  a  warm  room  into  the  cold  open 
air),  preceded  by  a  faulty  diet  or  a  sumptuous 
dinner  or  some  psychic  excitement.  But  the 
tabetic  crisis  is  independent  of  such  causative 
factors  and  comes  into  existence  with  a  leap, 
as  it  were,  and  without  apparent  reason. 

Basedow's  disease  is  likewise  guilty  of  at 
times  most  severe  retrosternal  pains  shooting  off 
into  both  the  upper  extremities.  These  char- 
acteristic and  obvious  symptoms  should  remove 
all  barriers  for  a  proper  diagnosis. 

Nervous  or  hysterical  angina  pectoris  is  dis- 
tinguished from  a  true  coronary  angina  by  the 
peculiar  behavior  of  the  patient.  Both,  how- 
ever, share  that  important  symptom  of  centri- 
fugal progression  into  one  or  the  other  arm, 
likewise  the  sensation  of  oppression  behind  the 
sternum  and  in  the  neck.  In  coronary  angina 
the  patient  remains  perfectly  still;  in  nervous 
angina  he  groans  and  cries  out  with  pain,  is 
extremely  restless,  and  makes  startling  move- 
ments. Still  these  distinguishing  manifestations 
do  not  always  serve  as  deciding  factors.  I  re- 
member a  case  of  lethal  angina  pectoris  in  which 


36  GENERALIZED   PAIN 

the  patient  rolled  about  the  floor  in  most  terrible 
pains.  Other  patients,  especially  males,  toss 
about  in  bed  in  the  most  restless  fashion,  con- 
stantly wailing  and  jabbering  and  gesticulating 
until  death  puts  an  end  to  the  agony.  Rosen- 
berg relates  cases  of  lethal  coronary  angina  in 
which  horrible  contortions  of  the  face  and  even 
arc  de  cercle  were  observed. 

The  hysterical  patient  often  describes  the  pain 
as  a  sensation  of  stretching,  a  feeling  of  fullness 
in  the  throat  emanating  from  behind  the  lower 
sternum.  But  in  coronary  angina  the  complaint 
is  more  of  the  sensation  of  compression  as  if  a 
heavy  weight  were  lying  on  the  chest,  as  if  the 
breast  were  held  in  a  vice,  also  the  feeling  of 
intense  burning  especially  in  the  region  of  the 
manubrium  of  the  sternum,  due,  at  least  in  part, 
to  reflex  contraction  of  the  intercostal  muscles. 

Pain  radiating  into  the  region  of  the  left  ul- 
nar  nerve,  even  into  the  fingers,  seems  to  point 
more  to  anatomical  than  to  nervous  angina 
pectoris. 

The  true  anginose  attack  occurs,  at  any  rate 
in  the  beginning  of  the  disease,  generally  at 
intervals  of  weeks  or  months,  preferably  in  the 
night  time.  The  individual  attacks  are  of  short 
duration.  In  nervous  pseudoangina  we  en- 
counter again  the  noisy,  theatrical  element.  The 
attacks  are  more  frequent,  30  to  40  follow  each 
other  in  rapid  succession,  mostly  in  the  day- 


HEART  37 

time  and  wind  up  in  tears  and  sighs  of  a  con- 
vulsive character.  The  basic  element  will  at 
times  assist  us  in  arriving  at  a  satisfactory  con- 
clusion. In  nervous  angina  pectoris  the  attack 
does  not  mature  from  a  bodily  movement,  but 
it  comes  on  top  of  a  psychical  emotion — in  true 
angina  pectoris  this  may  be  even  the  exclusively 
provoking  element — which  is  principally  condi- 
tioned by  a  special,  definite  external  cause,  e.g., 
when  entering  a  public  place  of  meeting,  a 
church,  a  theatre,  a  hall  filled  with  people  or 
when  attending  a  social  function.  The  object 
of  the  patient  is  to  have  all  eyes  turned  toward 
her  or  himself. 

The  blood  pressure  during  and  between  the 
attacks,  it  seems  to  me,  is  a  useful  point  of 
differentiation.  In  true  angina  pectoris  there  is 
generally  a  marked  rise,  but  between  the  attacks 
a  depression.  In  the  nervous  attacks  the  press- 
ure often  rises  considerably  during  the  attacks, 
but  no  marked  hypotension  is  noticeable  in  the 
intervals. 

The  presence  of  bradycardia  during  the  attack 
points  strongly  to  a  true  angina  pectoris.  Ab- 
normal difference  between  the  rectal  tempera- 
ture and  that  in  the  armpits  (0.6  to  1.0°  and 
above  in  favor  of  the  former)  speaks  for  true 
and  against  neurotic  angina  pectoris. 

Other  conditions  which  are  foreign  to  cases 
of  coronary  angina,  such  as  tachypnea,  true 


38  GENERALIZED   PAIN 

hysterical  or  nervous  stigmata,  abnormal  vita 
sexualis  point  to  hysterical  or  nervous  angina. 
To  avoid  dangerous  errors  it  will  be  well  to 
remember  that  the  so-called  hysterical  globus 
is  universally  accepted  as  an  important  hysterical 
stigma.  But  a  similar  sensation  may  also  be 
observed  in  true  coronary  angina.  Some  patients 
complain  that  in  stenocardiac  attacks  they  ex- 
perience the  feeling  of  constriction  in  the  fauces 
resp.  in  the  upper  esophagus.  This  has  been 
erroneously  accepted  by  some  as  a  globus 
hystericus,  and  in  consequence  a  false  diagnosis 
of  angina  pectoris  was  made. 

A  special  subdivision  of  nervous  angina  is 
what  might  be  called  angino phobia,  very  preva- 
lent among  the  members  of  the  medical  pro- 
fession. There  is  pressure,  pain,  so  to  speak, 
of  a  bursting  character  in  the  region  of  the 
heart  and  behind  the  sternum,  also  irradiation, 
oppression,  palpitation,  also  vasomotoric  mani- 
festations, psychic  affections,  especially  when 
recalling  the  picture  of  certain  morbid  symp- 
toms, but  hardly  ever  after  physical  strenuous 
efforts. 

In  this  negative  organic  state,  in  this  frequent 
persistence  of  pressure  sensation,  in  the  recurrent 
hyperesthesia  in  the  region  of  the  apex,  in  the 
psychical  provocation,  in  the  fact  that  the  patient 
admits  to  be  in  the  ban  of  a  morbid  conception 
that  forces  him  to  anticipate  a  threatened  attack 


HEART  39 

when  starting  some  physical  movement,  but 
absent  when  his  attention  is  averted  elsewhere, 
in  pronounced  psychic  depression,  or  hypo- 
chondriac moods,  difficulty  in  breathing,  also  in 
certain  minute  manifestations  which  are  in  abso- 
lute contrast  to  those  of  a  true  angina  pectoris, 
there  is  a  wealth  of  determining  factors  for  a 
correct  diagnosis. 

I  would  like  to  suggest  here  a  classification 
of  dyspragia  as  it  appears  in  different  parts  of 
the  body  (extremities,  heart,  intestines,  brain). 
In  the  first  place  I  would  put  the  purely  func- 
tional form  which  is  caused  by  absolute  vaso- 
constriction  in  which  the  walls  of  the  vessels 
remain  perfectly  intact  (purely  nervous  or  in 
nicotinism),  and  in  the  third  place  the  arterio- 
sclerotic  form  without  vascular  contractions.  In 
the  second  place  there  would  appear  that  form 
in  which  the  convulsive  attacks  based  on  vaso- 
constriction  are  provoked  by  the  arteriosclerosis 
itself;  I  mean  to  say,  the  existence  and  recur- 
rence of  which  is  conditioned  solely  in  the  ana- 
tomical defect  of  the  vessels  and  the  subsequent 
paroxysmal  vasoconstriction.  Then  there  is  a 
fourth  form  also  coupled  with  arteriosclerosis 
with  reflex  actions  on  the  vascular  nerves  by 
way  of  abnormal  stimulation,  yet  not  to  such 
an  extent  that  the  morbid  manifestations  of 
dyspragia  are  thereby  produced.  Only  when  an 
additional  extraneous  agent  which  increases  the 


40  GENERALIZED  PAIN 

stimulating  action  of  the  vasoconstrictors  forms 
a  union  with  the  arteriosclerosis  are  the  mani- 
festations of  dyspragia  elicited  and  maintained 
until  the  aforesaid  extraneous  agency  is  re- 
moved. So  far  as  prognosis  is  concerned  such 
a  classification  should  prove  of  importance.  For 
diagnostic  purposes  I  think  it  would  be  a  profit- 
able graduation.  Of  course,  in  some  cases  only 
the  final  outcome,  i.e.,  the  gradual  disappearance 
of  the  manifestations  would  bring  the  solution, 
although  the  anatomical  disease  itself  would 
continue  to  exist.  But  we  should  bear  in  mind 
that  the  retrogression  of  morbid  symptoms  may 
be  effected  through  collateral  channels,  especially 
in  those  cases  which  originate  exclusively  from 
anatomical  affections. 

In  the  differential  diagnosis  between  angino- 
phobia  and  a  true  coronary  angina  we  may  also 
bring  into  service  the  observation  that  in  the 
former  the  sensation  of  fear  consists  rather  of 
the  troublesome  suspicion  of  a  possible  disease  of 
the  heart  and  more  so  than  of  a  real  feeling  of 
oppression.  This  may  also  be  the  case  in  nervous 
hysterical  angina.  It  is  a  golden  rule  to  be 
exceedingly  conservative  when  making  a  diag- 
nosis of  absolute  nervous  angina  pectoris  in 
patients  who  have  gone  beyond  the  age  of  forty. 
In  most  cases  we  are  dealing  with  a  combination 
of  a  nervous  component  with  an  anatomical 


HEART  41 

arteriosclerosis  if  not  with  an  atypical  angina 
vera. 

Attacks  of  nervous  angina  pectoris  based  on 
sexual  neurotic  conditions  and  marked  by  op- 
pression, pain  in  the  cardiac  region,  anguish, 
and  even  final  collapse,  can  very  often  be  re- 
duced to  excessive  masturbation.  Other  points 
that  will  assist  in  a  correct  judgment  are  palpi- 
tation of  the  heart — a  symptom  wholly  foreign 
to  genuine  angina — also  the  localization  of  the 
pain  not  behind  the  sternum,  but  rather  in  the 
cardiac  region  proper  where  the  skin  especially 
around  the  apex  often  has  an  hyperesthetic 
appearance. 

In  vasomotoric  angina  pectoris  it  will  be 
noticed  that  the  patient  is  extremely  restless  and 
finds  relief  from  the  pain  by  constantly  moving 
about,  as  is  the  case  in  hysterical  angina.  The 
painful  attacks  are  frequently  combined  with 
palpitation  of  the  heart  and  are  preceded  by 
the  appearance  of  peripheral  angiospasms,  pal- 
lor, feeling  of  cold  or  acrocyanosis  of  the  extrem- 
ities and  of  the  face,  paresthesia  in  the  former, 
giddiness,  ague,  syncope  and  collapse,  generally 
relieved  by  cooling  applications.  Careful  obser- 
vation of  the  blood  pressure  is  a  useful  adjunct 
in  the  differential  diagnosis:  in  true  sclerosis 
of  the  coronary  arteries  a  marked  rise  in  the 
blood  pressure,  rarely  a  depression;  in  the  vaso- 


42  GENERALIZED   PAIN 

motoric  form  the  blood  pressure  is  but  slightly 
raised,  if  at  all,  but  not  over  20  mm.  Hg. 

Angina  pectoris  following  in  the  wake  of 
acute,  infectious,  and  also  at  times  chronic 
myocarditis  without  affections  of  the  coronary 
arteries  may  easily  be  recognized  by  its  anginose 
manifestations  of  a  clinically  inferior  character. 
It  very  likely  arises  from  an  irritation  of  the 
cardiac  nerves,  by  way  of  some  myocardial 
disorder,  in  the  same  manner  in  which  the  same 
trouble  springs  in  stenocardia  from  an  acute 
pericarditis. 

Mild  attacks  of  angina  pectoris  in  which  the 
patient  complains  only  of  pressure  in  the  cardiac 
region  and  behind  the  sternum  when  engaged 
in  bodily  movements  or  in  mental  action  may 
be  observed  in  myodegeneration  of  the  heart 
without  giving  rise  to  a  notable  sclerosis  of  the 
aorta  or  the  coronary  arteries.  At  any  rate  we 
have  no  clinical  proof  of  it.  What  arrests  the 
attention  is  rather  the  obvious  dullness  of  the 
heart  sounds  even  when  the  patient  is  leaning 
over  in  the  front,  the  smallness  of  the  peripheral 
pulse  and  a  splitting  of  the  heart  sounds.  The 
prognosis  is  much  more  possible  for  a  long  life 
if  good  care  is  taken  of  the  heart.  In  these 
cases  the  thought  always  lies  near  that  we  are 
rather  dealing  with  an  overstretching  of  the 
heart  during  some  physical  exertion. 

In  some  cases  of  paroxysmal  tachycardia  the 


HEART  43 

patient  ocmplains  of  severe  pains  behind  the 
sternum  with  extensions  into  the  arm,  obviously 
anginose  attacks  reduceable  to  an  ischemia  of  the 
myocardium.  Although  we  find  acceleration  of 
the  pulse  as  an  accompanying  symptom  in  pain- 
ful attacks  of  true  angina  pectoris,  this  should 
not  be  a  disturbing  element  in  making  a  proper 
diagnosis  of  paroxysmal  tachycardia  in  which 
the  pulse  rate  is  much  higher  (160  the  minimum, 
a  rate  never  obtained  in  coronary  sclerosis). 

It  is  worth  the  while  to  emphasize  here  the 
fact  that  attacks  of  coronary  angina  are  some- 
times accompanied  by  symptoms  which  are  apt 
to  lead  to  errors  of  a  serious  character  for  the 
patient  as  well  as  the  attending  physician. 

There  are  cases  of  true  angina  pectoris  of  the 
severest  type  in  which  the  sensation  of  anguish 
is  totally  wanting.  But  it  would  also  be  an 
error  to  infer  from  the  presence  of  this  sensation 
that  the  attack  rests  upon  an  anatomical  basis. 

It  cannot  be  disputed  that  the  true  steno- 
cardiac  attack  is  elicited  by  some  physical  move- 
ment. On  the  other  hand  there  are  cases  of 
true  angina  pectoris  in  which  the  attack  does 
not  follow  a  bodily  motion,  not  even  a  physical 
overexertion,  but  in  which,  the  same  as  in  nerv- 
ous or  hysterical  angina  the  spell  comes  only 
during  the  night  abruptly  shaking  the  patient 
out  of  his  sleep.  Other  patients  suffer  from  the 


44  GENERALIZED   PAIN 

evil  turn  by  day  as  well  as  in  the  night,  the 
nocturnal  attacks  generally  being  of  a  longer 
duration.  These  latter  cases  bear  unmistakable 
signs  of  coronary  sclerosis. 

Furthermore,  there  are  cases  in  which  no 
palpable  reason  for  the  occurrence  of  nocturnal 
anginose  attacks  can  be  discovered,  e.g.,  a  late, 
unusually  heavy  dinner.  They  come  spontane- 
ously without  any  recognizable  provocation,  and 
physical  exercise  seems  to  have  a  beneficent 
effect  on  the  patient.  And  yet  the  disease  is  a 
true  coronary  sclerosis  beyond  a  doubt.  Two 
of  my  patients  died  during  such  a  nocturnal 
attack.  The  same  observation  has  been  made  by 
others  (Cushman,  sen.) 

If  the  attacks  are  of  a  milder  type  it  might 
be  proper,  from  the  therapeutic  as  well  as  from 
the  diagnostic  standpoint,  to  advise  the  patient 
to  take  some  food  during  the  night  which  might 
forestall  a  possible  attack.  If  the  result  is 
favorable,  as  no  doubt  it  will  be,  it  would  be  a 
proof  that  the  nocturnal  attacks  coming  on 
during  the  resting  period  are  due  to  ischemia  of 
the  heart  derived  from  lessened  irrigation,  whilst 
bodily  effort  stimulates  the  circulation  in  the 
cardiac  muscles  and  thus  aborts  the  attacks. 

The  reverse  is  the  case  in  dyspeptogenoiis 
angina  pectoris,  in  which  the  intake  of  certain 
food  stuffs,  or  of  any  kind  of  food,  is  the  signal 
for  the  attack,  and  bodily  exercise  is  neutral 


HEAKT  45 

in  its  reaction.  In  this  peculiar  etiologic  factor 
the  clinician  may  find  a  hint  for  the  diagnosis; 
likewise,  according  to  French  authors,  in  the 
milder  character  of  the  attack,  its  longer  dura- 
tion and  less  dangerous  moment;  also  in  the 
undisputed  dilation  of  the  heart  during  the  at- 
tack and  in  the  accentuation  of  the  second 
pulmonary  sound.  But  I  share  with  Krehl  his 
doubts  on  the  subject.  What  I  have  seen  my- 
self were  true  cases  of  arteriosclerosis  in  which 
acute  dyspepsia  was  the  provocative  cause. 
Krehl  attributes  the  attacks  to  nervous  super- 
sensitiveness  of  the  heart.  As  a  rule  I  scent 
especially  in  older  patients  a  coronary  sclerosis 
as  the  exciting  focus. 

The  diagnosis  of  an  hysterical  angina  pectoris 
due  to  psychical  conditions  is  sometimes  used  as 
a  factor  in  the  differential  diagnosis  of  a  steno- 
cardia arising  from  a  sclerotic  affection  of  the 
coronary  arteries.  But  I  hesitate  to  subscribe 
to  such  an  opinion,  because  I  have  seen  cases  of 
true  stenocardia  which  beyond  a  doubt  originated 
from  psychic  emotions  rather  than  from  any 
bodily  exertion. 

Accompanying  polyuria,  urina  spastica,  is 
frequently  considered  an  important  symptom  of 
nervous,  hysterical  angina  pectoris.  But  this 
may  also  be  misleading.  I  remember  one  of 
the  gravest  cases  of  coronary  angina  with  poly- 
uria immediately  after  the  stenocardiac  attack. 


46  GENERALIZED   PAIN 

Polyuria  parallel  with  salivation  is  not  an  in- 
frequent obvious  reflex  action  of  a  stenocardiac 
attack. 

The  influence  of  cold  and  palpable  vaso- 
motoric  disturbances  preceding  the  attack,  par- 
esthesia,  shivering,  pallor  of  the  face  and  of  the 
extremities  may  be  looked  upon  as  decisive 
symptoms  in  vasomotoric  angina  pectoris.  But 
even  here  the  utmost  precaution  must  be  exer- 
cised. Cold,  to  be  sure,  is  one  of  the  principal 
causes.  A  sudden  change  from  the  atmosphere 
of  a  well  heated  room  into  the  cold  temperature 
out-of-doors,  or  the  cold  clammy  sheets  of  the 
bed  may  provoke  an  attack.  But  what  seems 
to  me  of  still  greater  import  is  the  fact  that 
vasomotoric  phenomena  may  also  come  before 
an  attack  of  true  coronary  angina.  Not  long 
ago  I  saw  a  patient  with  the  whole  characteristic 
symptom  complex  of  stenocardia.  The  post 
mortem  showed  the  presence  of  a  grave  mes- 
aortitis  and  mesarteritis. 

Vasomotoric  symptoms  may  also  be  observed 
in  both  the  upper  extremities,  or  perhaps  only 
on  one  side  of  the  body,  or  in  everyone  of  the 
four  extremities;  and  again  there  may  be  a 
periodic  constriction  of  a  bronchial  artery  as 
against  the  contralateral,  even  a  local  asphyxia, 
eventually  confined  to  one  side  only.  And  yet 
there  is  a  true  angina  pectoris. 

Vertigo   or   intermittent   unilateral    blindness 


HEART  47 

when  associated  with  stenocardiac  attacks,  are 
accompanying  vasomotoric  symptoms. 

It  seems  to  follow  that  at  the  very  best  only 
the  whole  complex  of  vasoconstringent  symp- 
toms in  its  entirety,  and  then  only  with  prudent 
reserve,  may  be  considered  as  indicating  vaso- 
motoric angina,  but  when  it  is  confined  to,  the 
narrow  limits  of  certain  corporeal  regions — 
mainly  the  left  upper  extremity — it  cannot  serve 
as  a  criterion  against  a  serious  coronary  angina. 

Certain  morbid  manifestations  which  suddenly 
make  their  appearance  during  violent  weather 
disturbances,  tornadoes,  simooms,  severe  thunder- 
storms, are  frequently  looked  upon  as  mere 
nervous  or  vasomotoric  disorders.  But  my  own 
experience  has  led  me  to  the  firm  conviction  that 
they  are  occasioned  by  these  disturbances  them- 
selves. 

There  is  a  series  of  painful  attacks  which 
present  themselves  in  a  manner  similar  to  those 
connected  with  angina  pectoris.  In  the  front 
rank  are  the  diseases  of  the  circulatory  appar- 
atus as  well  as  of  more  distant  organs.  I  refer 
here  first  to  those  diseases  which  have  already 
been  mentioned  as  the  source  of  very  intensive 
pains  in  the  region  of  the  heart.  In  a  rupture 
of  the  organs  referred  to  in  that  chapter  the  lo- 
cation of  the  pain  is  often  falsely  placed  in  the 
precordial  region,  sometimes  in  the  epigastrium 
or  the  abdomen.  In  consequence  it  is  errone- 


48  GENERALIZED    PAIN 

ously  taken  for  a  lethal  angina  pectoris.  Only 
the  proof  of  an  existing  hemopericardium  or  an 
acute  insufficiency  of  the  aorta  can  protect  us 
against  such  an  error  when  the  pain  is  properly 
localized  as  existing  in  the  precordium  and  not 
behind  the  sternum. 

Attacks  similar  to  those  in  true  angina  pec- 
toris— mostly  of  a  recurrent  nature — are  also 
produced  by  other  diseases,  especially  by  sclerosis 
of  the  pulmonary  artery.  But  then  the  patient 
complains  of,  besides  anguish  and  oppression, 
pain  in  the  cardiac  region  with  a  feeling  as  if 
this  pain  were  penetrating  away  down  into  the 
chest,  yet  without  irradiation  into  the  periphery 
which  is  so  charactertistic  of  coronary  sclerosis. 
There  is  but  little  shortness  of  breath  or  none 
at  all,  but  a  high  grade  cyanosis,  in  contradis- 
tinction to  pallor  in  angina,  or  to  the  slighter 
degree  of  cyanosis  in  stenocardia  springing  from 
mitral  stenosis.  The  differential  diagnosis  must 
be  determined  by  the  remaining  symptoms,  viz: 
generally  existing  abnormally  large  dilatation 
of  the  right  ventricle  with  simultaneous  primary 
stenosis  of  the  mitral  ostium,  the  unusual  reson- 
nance  of  the  second  pulmonary  sound,  dilata- 
tion of  the  pulmonary  artery,  and  eventually  a 
relative  insufficiency  of  the  pulmonary  valves. 

The  same  conditions  exist  in  those  isolated 
cases  of  pseudoanginose  attacks  which  arise  from 
thrombosis  of  the  pulmonary  artery  or  of  the 


HEART         «  49 

right  ventricle.  Notice  the  solitary  deepseated 
pain  associated  with  the  feeling  of  anguish, 
uyanosis,  rapid  asphyxia,  all  of  which  affect  the 
differentiation  of  coronary  angina.  But  when 
the  beginning  and  the  progress  of  such  a  throm- 
bosis is  only  gradual  we  may  observe  repetitions 
of  the  pseudoanginose  attacks  coupled  with 
cyanosis  and  dyspnea  and  even  with  distinct 
dilatation  of  the  right  ventricle.  The  accompany- 
ing cyanosis  and  dyspnea,  the  deepseated  pain 
devoid  of  peripheral  radiation,  and  regular  dila- 
tation in  the  right  region  of  the  heart  are,  indeed, 
the  guiding  points  in  the  differential  diagnosis. 

Embolism  of  the  trunk  of  the  aorta  leads  to 
pain  in  the  cardiac  sector.  Accompanying 
dyspnea  and  cyanosis,  deepseated  pain,  the 
missing  participation  of  the  affected  side  of  the 
thorax  in  the  breathing  rhythm,  bloody  sputum, 
and  above  all  the  conspicuous  frequency  and 
smallness  of  the  arterial  pulse  are  signs  full  of 
meaning  for  the  diagnosis. 

Painful  attacks  have  repeatedly  been  ob- 
served in  innate  pulmonary  stenosis.  The  de- 
termining factors  in  the  diagnosis  of  this  disease 
are:  systolic  crepitus  of  a  whirring  character  in 
the  second  intercostal  space  to  the  left  of  the  ster- 
num, in  the  left  interscapular  fossa  and  possibly 
in  the  left  carotid,  peripheral  cyanosis,  even- 
tually hypertrophy  of  the  left  ventricle,  tuber- 
culous lesions  in  the  lungs,  and  pre-senility  age. 


50  GENERALIZED   PAIN 

Tumors  in  the  right  ventricle  or  the  left 
auricle  deserve  mention  here.  But  I  will  say 
at  once  that  the  diagnosis  in  these  cases  will 
always  be  more  or  less  guesswork.  Perhaps,  the 
most  distinguishing  feature  in  this  connection  is 
hemorrhagic  pericarditis  which  so  frequently 
and  rapidly  accumulates  again  after  a  paracen- 
tesis.  In  addition  there  are  spasmodic  attacks 
of  suffocation  when  changing  the  posture  of  the 
body,  metastasis  of  Troissier's  ganglion,  inex- 
plicable embolism,  pronounced  cyanosis  mostly 
without  dyspnea  when  the  tumor  is  in  the  right, 
but  bloody  sputum  if  in  the  left  auricle. 

Indurated  mediastinitis  may  in  my  opinion 
occasion  similar  painful  attacks.  Pains  behind 
the  sternum  may  appear  during  a  walk,  only 
to  disappear  again  when  the  patient  sits  down 
to  rest,  likewise  painful  dysphagia.  The  most 
prominent  adjuvants  in  the  diagnosis  are  a 
strongly  marked  Oliver-Car 'darelli  sign  and  the 
Roentgenogram. 

Mediastinal  neoplasms,  e.g.,  a  lymphocarci- 
noma  may  at  times  simulate  an  angina  pectoris, 
for  in  this  state  the  patient  also  complains  of 
retrosternal  pain  experienced  during  walking  or 
accentuated  by  more  lively  physical  exercise. 
This  pain  is  undoubtedly  due  to  the  dragging 
of  the  mediastinal  tumor  in  the  more  vigorous 
respiratory  movements  of  the  chest. 

Pseudoangina  with  cyanosis  of  the  higher  type 


HEART  51 

may  also  be  found  in  thrombosis  of  the  superior 
vena  cava. 

Perforation  of  an  adjacent  organ  into  the 
pericardium  will  induce  sudden,  very  violent 
painful  attacks.  Sensation  of  anguish  and  col- 
lapse with  lethal  results  often  follow.  If  the 
perforated  organ  is  cavernous  (pulmonary  cav- 
ity, neoplasm  of  the  lung,  carcinoma  of  the 
esophagus)  we  have  before  us  a  pneumoperi- 
cardium,  with  classical  symptoms,  especially  in 
auscultation;  otherwise  it  is  pericarditis  which 
in  connection  with  the  initial  pains  should  facili- 
tate a  definite  diagnosis  unless  the  basic  disease 
*is  never  fully  recognized. 
Among  the  diseases  of  distant  organs  I  re- 
mind my  readers  here  of  the  perforation  of  an 
ulcus  ventriculi,  or  an  acute  peritonitis  originat- 
ing from  the  stomach,  i.e.,  gastric  volvulus.  In 
these  cases  we  may  even  come  across  a  very 
intensive  sensation  of  anguish  coupled  with 
acute  overwhelming  pains  in  the  region  of  the 
heart  resembling  in  every  detail  a  typical  attack 
of  coronary  angina.  But  when  we  consider  that 
in  angina  pectoris  the  pain  is  localized  rather 
behind  the  sternum  and  less  in  the  cardiac  region, 
and  concentrate  our  attention  on  the  pressure 
and  hammering  sensation,  the  tension  in  the 
epigastric  abdominal  wall,  occult  hemorrhages  in 
the  stools,  etc.,  we  shall  be  able  with  the  aid  of 
the  anamnesis  to  arrive  at  a  definite  diagnosis. 


52  GENERALIZED   PAIN 

If  the  attack  is  accompanied  by  vomiting,  once 
only  or  repeatedly,  I  would  look  upon  this 
symptom  as  an  indication  against  rather  than 
for  angina  pectoris,  unless  the  patient  has 
shown  signs  of  cerebral  or  syncopic  complica- 
tions. In  such  cases  vomiting  is  often  enough  a 
concomitant  symptom  in  angina  pectoris  and  of 
no  further  value  so  far  as  the  differential  diag- 
nosis is  concerned.  Furthermore,  if  vomiting 
occurs  in  the  intervals  between  the  attacks  as 
well  as  at  the  time  of  the  attacks  themselves,  this 
would  likewise  render  the  symptom  worthless 
for  differential  diagnostic  purposes,  for  it  would 
at  the  utmost  only  indicate  a  catarrhal  gastric 
congestion  arising  from  the  steadily  increasing 
insufficiency  of  the  heart  in  stenocardia.  Of 
course,  in  such  a  case  there  would  be  other 
admonitory  symptoms  of  cardiac  insufficiency 
present  such  as  tachycardia,  abnormal  weak- 
ness of  the  heart  beats  and  of  the  pulse,  embryo- 
cardia,  eventually  also  dilatation  of  the  heart 
and  additional  manifestations  of  congestion. 
Blood  pressure,  if  observed,  will  also  be  a  guid- 
ing symptom.  In  angina  pectoris  it  is  generally 
higher,  in  peritonitis  it  shows  a  downward 
tendency. 

If  a  patient  comes  to  you  complaining  of  a 
sudden,  perhaps,  recurrent  pain  of  a  spasm-like, 
crushing  pain  in  the  region  of  the  heart  and 
behind  the  sternum,  sometimes  even,  it  is  said, 


HEART  53 

with  a  radiation  in  the  left  arm  and  in  the  left 
trigeminal  region  associated  with  feelings  of 
anguish,  then  think  of  the  possibility  of  an 
existing  cholelithiasis.  The  pains  sink  deep  into 
the  epigastrium  and  into  the  right  hypochon- 
drium  with  excursions  into  the  dorsal  region. 
There  is  also  distension  of  the  liver,  tenderness 
in  the  notch  of  the  gallbladder,  febrile  attacks 
with  periodical  enlargement  of  the  cystic  bile 
ducts.  When  such  conditions  come  under  our 
observation  it  is  wise  to  follow  this  procedure: 
if  there  is  cardiac  pain  resembling  stenocardia 
make  a  thorough  examination  of  the  liver, 
especially  for  engorgement  under  palpation  and 
percussion,  sensitiveness  to  pressure  in  the  region 
of  the  notch  at  the  acme  of  the  inspiratory  act 
and  other  signs  of  a  gallbladder  colic;  do  not 
overlook  an  approaching  chill,  a  rise  in  the  body 
temperature,  irradiation  into  the  dorsal  region, 
hepatic  zones  of  the  skin,  and  urobilinuria.  If 
you  do,  you  will  avoid  missing  the  correct  diag- 
nosis of  an  angina  pectoris  situated  ad  portam 
hepatis,  and  in  error  bring  in  a  verdict  for 
anginose  or  pseudoanginose  attacks  when  it  is 
a  case  of  hepatic  colic. 

It  would  likewise  be  an  error  to  look  upon 
a  lesser  and  brief  rise  in  the  temperature  ob- 
taining during  an  attack  as  a  contraindication 
in  the  diagnosis  of  an  angina  pectoris,  for  it  is 
not  an  impossible  factor  in  these  affections. 


54  GENERALIZED   PAIN 

Myocarditis  and  myomalacia  are  by  no  means 
exceptional  offsprings  of  a  diseased  heart,  not 
to  speak  of  epistenocardiac  pericarditis. 

The  diagnostic  situation  may  become  more 
complicated  when  we  have  to  deal  with  a  patient 
who  complains  of  periodical  very  severe  pains 
behind  the  sternum  and  who  upon  examination 
shows  an  insufficiency  of  the  aorta.  Here  we 
are  apt  to  find  a  slight  dilatation  of  the  left 
ventricle,  a  sudden  nocturnal  attack  of  very 
violent  pains  behind  the  right  hypochondrium, 
thence  ascending  behind  the  sternum  to  the  level 
of  the  right  mamilla.  The  pains  may  settle  in 
this  region  and  persist  with  the  utmost  intensity; 
they  may  become  intermittent  or  remain  for 
hours  in  the  retrosternal  circumference.  I  have 
such  a  case  in  mind.  One  of  the  attending 
physicians  diagnosed  gastric  colic;  another,  vas- 
cular pains;  a  third,  achylia  of  the  stomach;  and 
a  fourth,  chronic  nicotinism.  But  suddenly  one 
of  the  attacks  was  followed  by  an  attack 
of  icterus  with  pronounced  bilirubinuria  which 
lasted  four  days.  This  led  to  a  final  diagnosis 
of  liver  colic.  The  patient  had  incomplete  in- 
sufficiency of  the  aorta,  a  positive  Wassermann 
— he  once  had  a  chancre — ,  the  liver  was  dispro- 
portionately enlarged  and  the  spleen  was  dis- 
tended. I  attributed  the  nightly  attacks  of  pain 
to  syphilis  of  the  liver.  The  absence  of  motoric 
pain,  the  long  intervals  between  the  attacks  for 


HEART  55 

months  at  a  time,  the  statement  made  by  the 
patient  that  flatus  per  anum  always  relieved  the 
distress,  the  fact  that  the  attacks  often  lasted  for 
hours  and  were  without  the  sensation  of  anguish, 
the  engorgement  of  the  liver  and  of  the  spleen 
and  the  almost  exclusive  arrival  of  the  attacks 
in  the  night  time,  should  have  been  sufficient  in- 
dications for  correcting  the  diagnosis  of  "liver 
colic." 

There  is  another  situation  in  which  errone- 
ously a  false  diagnosis  of  an  impending  abdomi- 
nal angina  pectoris  may  creep  in.  A  patient, 
seventy  years  of  age,  came  to  me  complaining  of 
sudden  sharp  pains  in  the  epigastrium  diagonally 
across  the  abdomen,  travelling  quickly  up  behind 
the  superior  region  of  the  sternum,  followed  by 
oppression  and  dyspnea  accompanied  by  rasp- 
ing sounds  in  the  chest  and  expectoration  of  a 
watery,  frothy  sputum.  My  first  thought  was 
of  angina  pectoris  with  cardiac  asthma,  resp. 
pulmonary  edema,  especially  so  as  the  patient 
bore  every  evidence  of  a  severe  arteriosclerosis 
and  very  strong  dilatation  in  the  left  ventricle, 
besides  a  muscular  mitral  insufficiency.  But  a 
more  mature  analysis  of  the  symptoms  brought 
me  to  the  conclusion  that  the  pains  did  not 
originate  from  an  angina  pectoris  at  all,  but 
rather  from  a  peracute  congestion  of  the  liver, 
for  the  liver  appeared  to  be  enlarged  and  the 
pain  in  it  on  pressure  resembled  in  localization 


56  GENERALIZED   PAIN 

and  character  in  every  detail  that  pain  which 
always  sets  in  with  the  attack.  Of  course,  the 
diagnosis  is  much  easier  if  one  has  the  oppor- 
tunity to  watch  the  patient  during  the  attacks  as 
well  as  in  the  intervals  and  observe  the  rapid 
fluctuations  in  the  size  of  the  liver  and  all  the 
other  symptoms  in  this  congested  organ  (also 
urobilinuria).  I  have  seen  three  such  cases  in 
which  there  were,  however,  also  pains  in  the  left 
epigastrium  and  behind  the  sternum  as  symp- 
toms of  the  peracute  engorgement  caused  by  pre- 
ceding physical  overexertion.  I  was  enabled  to 
make  a  correct  diagnosis  only  by  a  close  study 
of  the  patient  during  the  whole  time  that  the 
pain  lasted.  It  is  of  interest  to  know  that  in 
all  these  cases — they  were  men  over  fifty  years  of 
age  with  moderate  arteriosclerotic  myocarditis— 
the  pains  never  set  in  except  immediately  after 
brisk  bodily  movements.  With  rest  in  bed  they 
disappeared  again  within  three  or  four  days,  as 
did  also  the  engorgement  of  the  liver. 

A  similar  localization  of  the  "liver  pain"- 
frequently  it  is  rather  of  a  mild  and  not  colicky 
character — seems  to  occur  in  the  morbid  affec- 
tion of  the  left  lobe  of  the  liver,  be  this  condition 
of  a  concomitant  or  independent  nature.  It  has 
been  recently  described  in  a  case  of  acute  en- 
gorgement due  to  an  acute  spinllosis  of  the 
liver  (Plaut-Vincent) ,  a  concomitant  symptom 
of  Plant-Vincent's  angina. 


HEART  57 

But  not  only  a  hepatic  colic  but  a  painful 
attack  provoked  by  an  acute  necrosis  of  the 
pancreas  or  else  by  an  acute  pancreatitis  may 
be  localized  by  the  patient  in  the  cardiac  region 
and  in  consequence  erroneously  attributed  by  the 
attending  physician  to  angina  pectoris.  But  in 
such  a  case  the  diagnosis  of  an  acute  affection 
of  the  pancreas  should  be  made  without  diffi- 
culty on  the  ground  of  rise  in  the  temperature 
during  the  attack,  pressure  and  throbbing  sensa- 
tion in  the  epigastrium,  nausea,  vomiting,  bulg- 
ing of  the  epigastrium  and  possibly  in  the  region 
of  the  cecum  and  ascending  colon  while  the  rest 
of  the  abdomen  shows  no  signs  of  distention  but 
is  rather  sunk  in,  and  finally  and  especially  the 
acute  collapse. 

Among  the  chronic  affections  of  the  pancreas 
it  is  principally  carcinoma  which  gives  rise  to 
violent  crises  of  pain.  These  may  very  well 
wear  the  guise  of  an  angina  pectoris  when  reach- 
ing up  into  the  cardiac  territory,  which,  however, 
is  a  rather  unusual  coincidence.  But  the  absence 
of  irradiation  in  the  arm,  that  fan-like  extension 
of  the  pain  over  the  entire  abdomen  and  even 
into  the  sacrum,  together  with  the  other  typical 
symptoms  of  a  pancreatic  disease  should  proffer 
the  key  to  the  solution. 

We  have  already  mentioned  perforation  of 
a  tumor  into  an  adjacent  sphere  and  also  vol- 
vulus ventriculi  as  causes  of  very  intense  pain. 


58  GENERALIZED    PAIN 

It  is  meet  to  add  here  that  other  diseases  of  the 
stomach  may  elicit  pain  in  the  cardiac  and  in 
the  retrosternal  region,  with  irradiation  into  both 
arms,  and  that  this  pain  may  be  easily  mistaken 
for  an  anginose  attack. 

I  have  in  mind  here  that  form  of  angina 
pectoris  which  is  looked  upon  by  some  authors 
as  a  reflex  action  of  the  stomach.  I  have  never 
seen  such  a  case  myself.  The  cases  of  purely 
nervous  dyspepsia  with  secondary  nervous  an- 
gina pectoris  cannot  belong  here.  Neither  can 
those  of  purely  secondary  cardiac  neurosis  in 
which  strong  palpitation,  arythmia,  oppression 
and  the  feeling  of  anguish  are  the  prominent 
symptoms,  whilst  pain  is  of  subordinate  import. 
Of  course,  there  are  other  points  to  be  taken 
into  consideration,  such  as  anginoid,  similar  to 
those  in  stenocardia,  also  with  irradiation  in  the 
left  arm,  in  company  with  the  rest  of  the  symp- 
toms already  enumerated.  These  manifestations 
may  show  up  after  a  heavy  meal  and  disappear 
again  with  a  proper  regulation  of  the  digestive 
apparatus  by  the  aid  of  an  emetic  or  the  stomach 
pump.  Ravenous  eating,  insufficient  mastica- 
tion, overloading  of  the  stomach  seem  to  be  the 
essential  causative  factors  for  these  anginose 
attacks.  But  in  my  opinion  they  do  not  seem 
to  bear  the  convincing  stamp  of  an  existing  re- 
flex angina.  I  am  inclined  to  attribute  them  to 
a  preexisting  weakness  of  the  heart  or  to  an 


HEART  59 

affection  of  the  aorta  or  of  the  coronary  vessels, 
conditions  which  may  easily  give  rise  to  painful 
manifestations  when  spurred  by  an  acute  dis- 
turbance in  the  digestive  organs. 

But  I  admit  the  possibility  that  in  ulcus  ven- 
triculi — even  without  perforation — pain  may  rise 
from  the  epigastrium  upwards  behind  the  ster- 
num with  excursions  into  the  left  or  into  both 
shoulders  or  also  into  the  left  arm.  The  pain 
may  be  the  product  of  bodily  exertion,  especially 
when  an  adhesive  perigastritis  is  present,  the 
same  as  happens  in  a  true  angina  pectoris. 
Bicarbonate  of  soda  and  subsequent  belching 
promptly  relieve  the  situation.  Our  decision 
will  be  supported  by  the  proper  consideration 
of  local  muscular  tension,  sensitiveness  to  pres- 
sure in  the  epigastrium  in  ulcus  ventriculi,  local 
hyperesthesia  of  the  skin,  Boas's  pressure  point, 
vomiting  —  in  stenocardia  only  under  certain 
conditions — ,  examinations  for  occult  hemor- 
rhages and  the  Roentgenogram.  The  objective 
finding  of  an  arteriosclerosis  should  be  used  with 
the  utmost  discretion,  because  this  condition  ma- 
terially advances  the  formation  of  a  round  tumor 
in  the  stomach. 

Similar  conditions  prevail  in  rare  cases  of 
carcinoma  of  the  stomach.  There  also  the 
patient  complains  of  pains  behind  the  upper 
sternum  aggravated  by  walking  or  physical 
exertion  almost  exclusively.  If  however,  an 


60  GENERALIZED   PAIN 

arteriosclerosis,  especially  of  the  aorta  is  also 
present,  the  difficulties  will  be  considerably  in- 
creased and  only  the  most  careful  examination 
of  the  gastrointestinal  tract  together  with  the 
anamnesis  proffer  the  desired  help. 

Ulcus  and  carcinoma  ventriculi  lead  to  angina- 
like  pains  much  sooner  when  they  are  associated 
with  pylorostenosis.  Pylorostenosis  may  at  any 
time  resemble  stenocardia  on  account  of  its  pain- 
ful attacks.  In  these  colicky  affections  the 
patient  is  apt  to  complain  of  pressure  behind 
the  sternum,  of  pains  coming  on  in  the  night 
time  coupled  with  feelings  of  anguish,  oppression 
in  the  chest.  Ructus  brings  relief.  The  latter 
after  H2S,  the  colicky  character  of  the  pains, 
copious  vomiting,  sarcinae  in  the  vomitus  and 
stools  and  the  X-ray  are  the  typical  guides. 
A  combination  of  angina  pectoris  and  pyloro- 
stenosis is  not  an  uncommon  phenomenon. 

Intestinal  disturbances  such  as  stubborn  ob- 
stipation and  gastric  dyspepsia  may  also  pro- 
voke troubles  in  the  chest.  They  come  in  the 
form  of  anginose  attacks,  oppressive  pains  be- 
hind the  sternum,  sometimes  with,  at  other  times 
without  irradiations  just  as  in  true  angina  pec- 
toris. The  differential  diagnosis  between  a  re- 
flex or  toxic  angina  pectoris  and  a  true  steno- 
cardia can  only  be  decided  when  we  have  definite 
proof  that  the  anginose  manifestations  abso- 
lutely coincided  with  the  gastric  disturbances 


HEART  61 

and  that  the  former  disappeared  with  the  cessa- 
tion of  the  latter.  It  is  well  also  to  bear  in 
mind  that  there  is  a  strong  connection  between 
true  anginose  attacks  and  constipation  and  the 
accompanying  straining  efforts  to  expel  the 
scybala.  In  some  of  these  cases  a  possible  weak- 
ness in  the  cardiac  vessels,  that  is  a  slight  inclina- 
tion to  vasoconstriction  might  attract  our  atten- 
tion. I  have  in  mind  here  male  patients  who 
have  been  treated — properly  or  insufficiently,  it 
matters  not — for  syphilis  and  in  whom  there 
may  be  a  suspicion  of  a  syphilitic  coronaritis. 
When  the  patient  tells  us  that  brisk  walking 
causes  a  slight  oppression,  and  we  find  a  posi- 
tive Wassermann  reaction,  especially  in  syphili- 
tic suspects,  we  may  gather  valuable  information 
about  such  anatomical  lesions  in  the  vessels  of 
the  heart. 

The  discharge  of  mucous  masses  from  the 
canal  in  colitis  membranacea  is  also  reputed  to 
bring  about  attacks  of  precordial  pains  of  an 
anginose  type  through  a  spastic  reflex  action  on 
the  coronary  arteries.  I  have  never  had  the 
opportunity  of  seeing  such  a  case. 

The  differential  diagnosis  of  true  angina  pec- 
toris  and  certain  neuralgias  craves  special  atten- 
tion in  this  place.  I  have  previously  mentioned 
that  angina  pectoris  very  often  sets  in  with  vaso- 
motoric  manifestations  in  the  left  upper  extrem- 
ity. It  may  be  added  here  that  if  it  appears 


62  GENERALIZED    PAIN 

on  the  ulnar  side  of  this  extremity  it  may  be 
accepted  as  the  first  signal  of  an  anginose  at- 
tack. This  pain  starts  from  its  accustomed 
irradiation  field,  ascends  to  the  shoulder  and  then 
settles  behind  the  sternum  resp.  in  the  cardiac 
region.  In  some  cases  it  specializes  only  in  the 
upper,  in  others  only  in  the  fore-arm.  There  is 
a  certain  resemblance  to  thoraco-brachial  neural- 
gia. This  may  become  so  accentuated  that,  as  it 
happens  in  true  angina  pectoris,  paresthesias 
and  hyperesthetic  zones  continue  to  prevail, 
especially  in  the  ulnar  region,  for  a  considerable 
time  after  the  attack.  The  affected  (nearly 
always  the  left)  arm  becomes  so  sensitive  that 
even  the  slightest  touch  evokes  intensive  pain. 
In  these  cases  the  evidence  of  typical  pressure 
points,  the  sensation  of  weight  and  stiffness,  the 
sensibility  disturbances  in  the  affected  part,  and 
the  accentuation  of  pain  when  moving  the  upper 
extremity  involved,  are  the  deciding  factors. 

Of  course,  when  the  pain  is  entirely  confined 
to  the  chest  and  when  irradiation  does  not  exist, 
the  question  will  naturally  arise:  Is  it  angina 
pectoris  or  intercostal  neuralgia?  The  evidence 
of  typical  pressure  points  will  speak  for  the 
latter.  Additional  proof  for  the  differential 
diagnosis  will  be  found  in  the  circumstance  that 
intercostal  neuralgia  does  not  show  that  axio- 
matic dependence  on  bodily  movement  which  is 
so  conspicuous  in  most  cases  of  angina  pecto.ris4 


HEART  63 

But  there  is  another  condition  which  may 
intervene  here  as  a  disturbing  element.  There 
are  cases  of  true  coronary  sclerosis  without  aneu- 
rysm  of  the  aorta  or  even  without  a  considerable 
distension  of  the  aorta  itself  in  which  anginose 
pains  are  felt  not  only  behind  but  simultaneously 
also  to  the  right  and  left  of  the  sternum,  gen- 
erally in  the  second  or  third  intercostal  space; 
likewise  laterosternal  pressure  points  on  both 
sides  as  well  as  in  the  second  and  third  inter- 
costal space  on  the  level  of  the  mamillary  line. 
The  resemblance  to  intercostal  neuralgia  be- 
comes thereby  still  more  marked. 

Although  hyperalgesias  of  the  skin  over  the 
left  breast  in  a  more  or  less  extended  circum- 
ference are  often  enough  noticeable,  it  seems  to 
be  rather  difficult  to  demonstrate  in  most  cases 
the  other  lateral  and  retrosternal  pressure  points 
of  intercostal  neuralgias.  This  fact  alone,  inde- 
pendently of  the  other  findings,  the  causative 
agents  of  the  attack  and  the  remaining  accom- 
panying symptoms,  appears  to  be  the  most  reli- 
able guide  to  a  correct  differential  diagnosis. 

Sometimes  an  angina  pectoris  is  erroneously 
diagnosed  when  it  is  in  reality  a  neuritis  of  the 
phrenic  nerve.  Here,  too,  the  patient  complains 
of  sudden  severe  pains  in  the  chest  with  heavy 
oppression.  But  the  differences  are  consider- 
ajble.  Regardless  of  the  basic  disease  (pleuritis, 
pneumonia,  pericarditis,  subphrenic  inflamma- 


64.  GENERALIZED   PAIN 

tion,  polyneuritis)  of  a  neuritis  of  the  phrenic 
nerves  and  the  incumbent  rise  in  the  tempera- 
ture we  find  here  generally  very  pronounced 
dyspnea  in  superficial  breathing,  while  in  angina 
pectoris  the  patient  breathes  without  hindrance, 
or,  perhaps  with  reserve,  i.e.,  as  little  and  as 
lightly  as  possible  in  order  to  forestall  pain. 
Cardiac  asthma,  however,  may  coexist,  not  neces- 
sarily, but  if  it  does  it  may  be  readily  recognized 
from  the  sputum  and  other  pulmonary  condi- 
tions. Moreover,  in  neuritis  of  the  phrenic  nerve 
the  typical  pressure  points,  singultus  are  in 
evidence,  whilst  death-agony  is  absent,  fear  of 
suffocation  prevails. 

Vagus  neurosis  of  a  purely  functional  nature 
may  also  assume  the  appearance  of  angina 
pectoris.  Severe  oppression  in  the  chest  arising 
from  the  stomach,  most  intensive  pains  with 
death-agony,  a  sensation  as  if  the  heart  came 
suddenly  to  a  standstill,  followed  by  an  abnor- 
mally quickened  cardiac  activity  are  among  the 
salient  features.  Negative  organic  conditions 
carry  no  importance,  but  strongly  symptomatic 
are:  high  grade  dyspnea,  volumen  pulmonum 
auctum,  a  host  of  vasomotoric  manifestations 
such  as  chills,  a  general  feeling  of  cold,  pallor 
of  hands  and  feet — signs,  all  of  which  fit  in  the 
frame  of  vasomotoric  angina  pectoris. 

Anginose  attacks  come  to  the  surface  not 
only  in  functional  disturbances  of  the  vagus— 


HEART  65 

Gowers'  so-called  vasovasal  affections — but  also 
in  anatomical  lesions  of  the  nerve  itself.  Physio- 
logic observations  show  that  the  vagus  nerves 
carry  vasoconstricting  fibers  to  the  coronary 
vessels.  It  follows  that  an  angina  pectoris  may 
be  the  possible  outcome  of  an  irritation  of  this 
nerve.  Variot  has  observed  a  similar  condition 
in  children  suffering  from  tuberculosis  of  the 
bronchial  glands  assumed  to  be  due  to  vagus 
compression. 

Fusiform  dilatation  of  the  esophagus  needs 
to  be  mentioned  here.  Mechanically  irritating 
particles  of  food  may  cause  the  rise  of  gases  or 
the  acid  contents  of  the  stomach,  and  the  pas- 
sage of  a  dilated  piece  of  food  may  occasion  a 
sudden  spasm  in  the  muscles  of  the  esophagus 
and  thus  cause  very  intensive  spastic  pains  be- 
hind the  sternum  with  a  feeling  of  a  heavy 
weight  on  the  chest  and  in  the  stomach,  with 
anguish  and  dyspnea.  The  pain  may  even  sneak 
along  the  ribs  in  the  form  of  an  intercostal 
neuralgia,  and  also  radiate  to  the  shoulders  and 
arms. 

The  diagnosis  should  offer  no  difficulties  if 
we  keep  our  eye  fixed  on  the  typical  manifesta- 
tions such  as  congestion  of  food,  regurgitation, 
fits  of  coughing  and  dysphagia,  also  a  puriform 
dilatation  of  the  stomach  due  to  a  cavity  above 
the  latter,  stagnation  of  foodstuffs  which  may 
easily  be  separated  by  physical  and  chemical 


66  GENERALIZED   PAIN 

examination  from  the  stomach  contents;  and 
the  X-ray.  The  proof  of  a  bipolar  occlusion 
of  the  cavity  above  the  stomach  can  be  estab- 
lished when  the  flow  of  the  water  through  the 
stomach  tube  comes  to  a  sudden  stop. 

Every  form  of  esophageal  spasm,  no  matter 
of  what  origin,  may  resemble  angina  pectoris. 
The  main  differential  points  are  these:  the  vic- 
tim of  a  stenocardial  attack  complains  of  a 
painful  feeling  in  the  chest  as  if  he  had  swal- 
lowed too  large  or  too  hard  a  morsel,  and  of 
spontaneous  or  forced  belching. 

Moreover,  the  pains  in  spasms  of  the  esopha- 
gus, generally  located  behind  the  lower  sternum, 
are  frequently  coupled  with  dyspnea,  feeling  of 
anguish,  palpitation  of  the  heart,  and  fainting 
spells — not  unknown  in  angina  pectoris  either. 
The  resemblance  between  the  two  diseases  is 
very  strong.  But  the  differentiation  ought  to 
be  assisted  by  the  thought  that  the  esophageal 
attack  is  directly  due  to  the  act  of  deglutition 
(the  intake  of  food),  a  causal  moment  which  in 
the  anginose  attack  is  lacking.  If  in  some  cases 
spastic  attacks  in  the  esophagus  cannot  directly 
be  attributed  to  the  swallowing  of  food,  yet  the 
cause  will  ever  lie  in  the  act  of  deglutition,  i.e., 
the  swallowing  of  saliva — dry  gulping.  Still 
another  cause  may  be  found  in  a  central  or  peri- 
pheral lesion  of  the  vagus.  The  stomach  pump, 
the  X-ray  and  eventually  esophagoscopy  should 


HEART  67 

remove  any  remaining  doubts.  It  is  noteworthy 
also  that  at  times  solid  food  will  pass,  while 
liquids  provoke  spasms. 

Yet,  there  are  cases  in  which,  quite  indepen- 
dently of  gulping,  a  feeling  of  spastic  contrac- 
tion rises  from  the  region  of  the  cardia  to  within 
about  the  lower  third  of  the  sternum.  It  is  an 
undulating,  cramp  -  like,  ascending  sensation 
which  after  a  few  moments — less  than  a  minute 
—recedes,  only  to  repeat  again  a  second  or  a 
third  time  and  finish  with  a  belch.  No  difficulty 
in  deglutition  is  experienced.  In  my  opinion 
we  are  dealing  here  with  a  sensibility  neurosis 
in  the  section  of  the  cardia  and  the  lower  third 
of  the  esophagus,  an  esophagalgia,  a  true  car- 
dialgia.  To  accept  the  term  "cardialgia"  as  iden- 
tical with  gastric  spasm  I  consider  misleading, 
"Gastralgia"  is  the  proper  name  that  should 
attach  to  the  latter  complaint.  It  is  not  unlikely 
that  some  forms  of  cardia — esophagalgia,  in- 
clining to  enteralgia,  is  connected  with  a  concur- 
rent motility — neurosis  of  a  lesser  degree.  I 
look  upon  it  as  the  expression  of  an  anatomical 
lesion  of  the  esophagus,  the  accompanying  mani- 
festation of  an  esophageal  diverticulum,  a  peptic 
ulcer  of  the  esophagus.  This  would,  no  doubt, 
render  the  diagnosis  much  easier. 

In  some  cases  indubitably  a  true  neurosis 
exists,  rarely  idiopathic  in  its  nature,  but  rather 
a  reflex-neurosis  emanating  from  the  gastro- 


68  GENERALIZED   PAIN 

intestinal  canal — an  upshot  of  acute  indigestion 
with  diarrhea — a  sign  of  habitual  excess  in  smok- 
ing, especially  of  cigarettes;  perhaps,  a  func- 
tional vascular  pain  in  the  affected  region,  an 
intermittent  esophageal  dyspragia  due  to  nico- 
tinism. When  the  originating  cause  is  not  quite 
so  palpable,  an  error  as  to  angina  pectoris  will 
be  obviated  when  we  observe  that  the  patient 
seeks  relief  in  walking  about  and  shows  no  signs 
of  oppressing  anguish.  In  cases  of  doubt  the 
following  points  will  be  of  assistance:  the  pains 
extend  from  the  region  of  the  xiphoid  process 
to  about  the  lower  third  of  the  esophagus  and 
not,  as  in  angina  pectoris,  higher  up  behind  the 
corpus  sterni;  the  ascending,  undulating  move- 
ment of  the  cramps,  and  the  fact  that  the  pain 
is  not  due  to  physical  exertion,  but  rather  re- 
lieved by  it.  I  have  come  across  several  cases 
of  cardia-esophagalgia  in  sclerosis  of  the  thor- 
acic aorta.  This  might  be  a  sympathetic  or 
causative  reflex  action  of  the  vagosympathieus. 
But  why  not  the  result  of  a  minor  constriction 
at  the  portal  end  of  the  esophageal  artery  or 
a  sclerosis  of  the  same?  If  that  is  so  then  these 
pains  which  are  so  similar  to  anginose  attacks 
and  frequently  accompanied  by  difficulty  in 
deglutition  would  be  nothing  else  than  a  true 
dyspragia  intermittens  angiosclerotica  esophagi 
based  on  anatomical  conditions.  This  conten- 
tion, however,  is  open  to  discussion  and  further 


HEART  69 

research.  Should  it  prove  correct,  another  dif- 
ficulty— but  not  insuperable — would  be  added 
to  the  differential  diagnosis. 

For  other  affections  of  the  esophagus  the 
reader  is  referred  to  the  chapter  on  "Pains  in 
the  Chest." 

The  fact  that  in  angina  pectoris  the  irradia- 
tion sphere  is  so  prominently  localized  in  the 
occipital  region,  or  in  the  teeth  or  in  the  left 
lower  maxilla  is  frequently  the  cause  for  an 
erroneous  diagnosis  of  occipital  or  trigeminal 
neuralgia,  and  that  angina  pectoris  may  also 
give  rise  to  pains  in  the  epigastrium,  in  the  porta 
hepatis,  in  the  lumbar  region,  and  may  even 
reach  out  into  the  testicles,  especially  the  left 
one,  and  also  into  the  lower  extremities,  should 
not  be  left  unnoticed.  I  refer  the  reader  to  my 
book  on  "Abdominal  Pain,"  Rebman  Company, 
New  York. 

I  have  repeatedly  pointed  out  that  dypnea 
is  not  to  be  considered  as  an  important  factor 
so  far  as  angina  pectoris  is  concerned,  but  that 
it  should  rather  lead  us  in  the  direction  of  a 
vagus  stenocardia  no  matter  whether  the  affec- 
tion of  the  vagus  nerve  is  of  an  anatomical  or 
functional  nature.  The  probability  is  that,  when 
stenocardia  and  dyspnea  appear  together,  car- 
diac asthma  has  associated  itself  with  the  angi- 
nose  attack.  It  is  quite  natural  that  in  these 
cases  we  witness  a  mixed,  principally  an  expira- 


70  GENERALIZED   PAIN 

tory  dyspnea,  and  that  the  stenocardiac  pallor 
is  due  to  hepatic  conditions.  But  even  under 
this  assumption  and  also  in  the  total  absence 
of  cardial  asthma  and  a  cardiac  pulmonary 
edema  arising  therefrom,  the  diagnosis  should 
offer  no  difficulty.  The  periodicity  of  the  mani- 
festations must  here  be  carefully  studied  in  order 
to  understand  the  connection  between  the  exist- 
ing asthmatic  and  stenocardiac  conditions,  a 
combination  which  prevails  particularly  also  in 
thrombosis  or  embolism  of  the  coronary  arteries. 
In  every  case  of  angina  pectoris  a  thorough 
scrutiny  of  the  aortic  and  cardiac  conditions 
becomes  a  necessity,  especially  for  the  presence 
of  an  aneurysm  in  the  aorta.  The  latter  as  well 
as  stenocardia  equally  arise  from  the  same  arte- 
rial affections,  for  which  reason  they  are  fre- 
quently companions.  Some  authors  claim  that 
in  this  connection  stenocardia  is  due  to  neuritic 
affections  of  the  aortic  plexus,  but,  so  far  as  I 
know,  a  definite  proof  for  this  assertion  has  not 
as  yet  been  advanced.  I  have  seen,  however, 
cases  of  periaortitis  and  plexus  neuritis,  i.e.,  a 
lesion  of  sympathicus  and  vagus  fibres  arising 
from  a  primary  sclerosis  of  the  aortic  intinia. 
There  were  present  arteriosclerosis  of  the  ascend- 
ing aorta,  recurrent  asthmatic  attacks,  moderate 
attacks  of  angina  pectoris  and  persistent  sym- 
patheticus  paresis  of  the  eyes  and  of  the  left  side 


HEART  71 

of  the  face.  The  post  mortem  only  can  estab- 
lish an  affection  of  the  aorta. 

A  question.  Is  there  such  a  thing  as  febrile 
stenocardia  due  to  disease  of  the  aorta  or  of  the 
coronary  arteries?  I  once  saw  a  patient  who 
complained  about  pains  stretching  diagonally 
across  the  breast,  especially  behind  the  sternum 
whether  he  was  in  motion  or  at  rest.  Subfebrile 
temperature  for  three  weeks  or  more.  The  at- 
tending physicians  diagnosed  influenza.  I  found 
a  slight  aneurysmatic  dilatation  of  the  aorta  and 
of  the  left  ventricle  and  a  positive  Wassermann 
as  the  patient  admitted  that  he  had  had  syphilis. 
My  diagnosis  was  angina  pectoris  due  to  syphi- 
litic febrile  aortitis.  I  saw  this  patient  again 
later  on  in  a  very  severe  anginose  state. 

When  the  attacks  of  true  stenocardia  come 
in  such  rapid  succession  that  there  is  scarcely 
an  interval  between  them,  we  speak  of  a  status 
anginosus.  This  does  not,  however,  render  the 
diagnosis  more  difficult,  unless  there  is  an  abnor- 
mal situation  in  the  pain  itself.  But  if  this  is 
not  present,  a  confusion  between  such  a  state 
and  epistenocardiac  pericarditis  seems  to  me 
excluded.  True,  the  patient  complains  of  con- 
stant pain  in  the  region  of  the  heart;  but  this  is 
jaot  as  intense  as  the  anginose  pain  is,  and  less 
connected  with  violent  sensations  of  anguish  or 
not  at  all.  There  is  rise  of  temperature,  peri- 
cardiac  friction  and  signs  of  fluid  pericardiac 


72  GENERALIZED   PAIN 

cxudates.  It  is  worthy  of  notice  that  after  an 
epistenocardiac  pericarditis  the  anginose  attacks 
discontinue;  also  that  an  ordinary  acute  peri- 
carditis may  produce  a  modified  status  angi- 
nosus.  The  slight  rise  in  the  temperature  should 
forestall  any  mistake  so  far  as  epistenocardiac 
myocarditis  is  concerned  in  this  connection. 

It  is  much  easier  to  err  in  the  direction  of 
crises  gastriques  due  to  tabes,  or  other  spinal 
affections  or  also  to  diabetes  mellitus.  Generally 
speaking,  they  dwell  in  the  epigastrium  or  in 
the  entire  abdominal  cavity,  but  may  localize 
at  times  exclusively  in  the  region  of  the  heart. 
But  the  presence  of  vomiting,  "dry  vomiting," 
the  fact  that  the  pains  are  not  so  much  localized 
behind  the  sternum  than  rather  in  the  cardiac 
region,  the  other  typical  signs  of  tabes  or  other 
causative  diseases,  should  secure  the  diagnosis. 
Difficulties  might  be  encountered  when  tabes  or 
diabetes  mellitus  are  also  associated  with  insuf- 
ficiency of  the  aorta,  in  which  case  a  diagnosis 
of  angina  pectoris  might  possibly  result.  But 
such  an  error  can  be  easily  avoided  if  due  regard 
is  given  to  the  typical  symptoms  of  these  gastric 
crises,  proper  localization  of  the  pains  is  made 
and  the  periodicity  of  the  attacks  is  observed. 


Pain  in  the  Sacrum 

In  cases  of  pain  in  the  sacral  region  let  the 
patient  first  of  all  show  the  exact  spot  where 
the  pain  is  felt.  Pain  in  the  back  is  such  a 
general  term  among  the  people  at  large  that 
no  specific  meaning  attaches  to  it.  With  some 
it  means  the  lumbar,  with  others  the  mesial  or 
also  the  sacral  region,  for  which  reason  it  is 
quite  proper  here  to  give  due  consideration  to 
all  the  morbid  conditions  that  may  occur  in  these 
different  sections.  For  fuller  particulars  see 
my  book  on  "Abdominal  Pain."  Upon  closer 
examination  it  is  generally  found  that  the  patient 
eventually  locates  the  seat  of  the  pain  above  the 
ilium  below  the  12th  rib,  in  other  words  in  the 
direction  of  the  caudal  section,  that  is,  the  region 
of  the  sacrum. 

If  the  pain  is  lodged  in  the  lower  two-thirds 
of  the  lumbar  region,  it  portends  undoubtedly 
trouble  in  the  muscular  tissue.  These  pains  in 
the  small  of  the  back  are  provoked  by  gymnastic 
exercises,  digging  in  the  garden,  or  chopping 
wood  or  any  kind  of  physical  over-exertion. 
But  also  in  normal  constitutions  they  may  be 
due  to  want  of  rest  and  loss  of  sleep,  and  are 
found  in  myasthenia,  in  debility  of  the  muse. 

73 


74  GENERALIZED   PAIN 

erect,  trunci,  in  Basedow's  disease  and  in  tetany, 
likewise  in  all  youthful  individuals  with  a  weak 
muscular  system.  The  derivation  of  the  pain 
and  the  tenderness  to  touch  in  the  affected 
muscles  are  sure  guides  for  the  diagnosis.  The 
same  pains  are  experienced  also  after  a  long 
surgical  major  operation,  likewise  in  the  spring 
when  heavy  clothing  is  discarded  for  the  lighter 
apparel  of  the  season.  Emaciated  people  have 
the  same  experience  owing  to  an  overburdening 
of  the  muscles  in  the  loins.  And  who  has  not 
felt  that  pain  after  standing  on  one's  feet  for 
a  long  time  or  after  stooping  down  repeatedly? 

This  same  pain  is  the  steady  companion  of 
certain  infectious  diseases.  It  springs  from  a 
myalgia  obtaining,  for  instance,  in  the  secondary 
stages  of  syphilis  before  and  with  the  advent 
of  exanthema  and  other  muscular  pains  in  the 
extremities.  In  this  connection  the  pains  are 
generally  sharper  in  the  night  time.  The  lum- 
bar pains  which  generally  follow  in  the  wake  of 
various  infectious  diseases  rest  on  the  same  basis, 
i.e.,  musculo-asthenic  or  else  nervous.  As  a  rule 
they  travel  in  company  with  general  fatigue, 
muscular  aching  in  the  legs  and  low  vitality 
power;  they  disappear  with  progressing  conva- 
lescence and  the  gaining  of  strength. 

Lumbago  is  without  doubt  the  most  formi- 
dable muscular  pain  in  the  lumbar  region.  It 
may  come  on  in  the  form  of  an  acute  attack, 


SACRUM  75 

or  may  exist  as  a  chronic  myalgia.  In  the 
former  case  it  arrives  suddenly  with  a  sharp 
rapid  pain;  the  latter  is  of  a  creeping,  insinuat- 
ing character.  It  would  be  an  error  to  rest  the 
diagnosis  upon  the  assertion  made  by  the  patient 
that  the  pain  is  sharpened  by  bodily  movement 
or  when  stooping  down  and  trying  to  erect  the 
body  again.  The  same  manifestation  occurs  in 
spinal  diseases  and  in  intraabdominal  affections, 
for  instance,  of  the  kidneys,  the  stomach,  the 
intestines,  the  abdominal  aorta,  etc.  The  distin- 
guishing symptom  in  the  diagnosis  of  lumbago 
is  the  exquisite  tenderness  to  touch  of  the  in- 
volved muscles,  especially  of  the  musculus  long- 
issimus  dorsi,  or  sacro-lumbalis  and  musculus 
quadratus  lumborum.  In  addition  there  are: 
hyperalgesia  of  the  skin  to  the  electric  current, 
scoliosis  in  the  lumbar  segment  (nearly  always 
on  the  sound  side),  the  missing  transformation 
of  the  physiologic  lumbar  lordosis  by  erect  pos- 
ture into  an  arching  kyphosis  by  a  thoracic 
forward  movement,  the  limitation  of  the  lateral 
movement,  the  "ludicrous"  sort  of  pain. 

A  traumatic  affection  of  the  lumbar  muscular 
system,  the  rupture  of  a  muscular  fasciculus  or 
fibre  (traumatic  lumbago)  may  easily  be  mis- 
taken for  the  common  form  of  lumbago.  The 
differential  diagnosis  should  not  offer  any  diffi- 
culties in  this  connection. 

If  the  pain  has  come  on  very  suddenly  after 


76  GENERALIZED   PAIN 

or  during  an  overexertion,  e.g.,  lifting  a  very 
heavy  burden,  and  if  the  patient  has  never  been 
subject  to  rheumatouratic  troubles  and  there  is 
evidence  of  painful  indurations,  cords,  callosities 
in  the  affected  muscles,  we  must  look  for  a 
muscular  rupture.  But  do  not  forget  that  uratic 
arthralgia  or  arthritis,  or  uratic  myalgia  or 
myositis  is  often  associated  with  a  local  trauma. 
Whenever  a  headache  comes  on  very  suddenly 
our  attention  should  be  directed  to  the  possi- 
bility of  some  acute,  painful  muscular  affection, 
especially  in  the  lumbo-sacral  sphere.  Tetanus, 
for  instance,  sets  in  with  pains  in  the  sacrum. 

When  these  pains  in  the  sacrum  are  very 
persistent,  especially  in  persons  of  unusual  girth, 
our  thoughts  should  be  turned  to  those  morbid 
processes  in  which  an  extravagant  lordosis  of  the 
lumbar  vertebrae  exists  with  subsequent  unusual 
weariness.  This  is  frequently  the  case  in  the 
later  stages  of  pregnancy,  and  is  also  observed 
in  invalids  who  walk  about  with  large  ascites 
(due  to  cirrhosis  of  the  liver)  or  with  a  big 
tumor  in  the  abdominal  cavity  (ovarian  cysts). 
The  pains  disappear  with  the  removal  of  the 
cause. 

Lumbar  pains  in  people  with  a  pendulous 
abdomen  are  often  enough  associated  with  other 
abdominal  disorders,  such  as  enteroptosis.  We 
find  here  anomalies  of  the  intraabdominal  circu- 
lation, a  dragging,  pulling  sensation  in  the 


SACRUM  77 

mesenterium,  sometimes  only  as  a  manifestation 
in  part  of  a  generalized  habitus  asthenicus  in 
which  the  patient  is  apt  for  muscular  reasons 
—impaired  condition  of  the  locomotorium — to 
complain  of  lumbar  pain.  A  quick  recognition 
of  the  stigmata  of  the  so-called  constitutional 
anomalies  such  as  a  chicken-breast,  or  a  flat, 
long  thorax,  a  sharp  epigastric  angle  and  a  10th 
costa  fluctuans,  should  soon  clear  up  the  sit- 
uation. 

Any  kind  of  static  overstraining  of  the  spinal 
column  due  to  anomalous  conditions,  e.g.,  flat- 
foot,  may  give  rise  to  pains  in  the  sacral  region 
and  in  that  way  resemble  lumbago.  The  same 
may  be  said  when  lameness  or  the  abbreviation 
of  one  limb  puts  a  special  task  upon  the  other 
lower  extremity;  also  in  lumbar  lordosis  due  to 
the  wearing  of  high  heels  on  the  shoes. 

Pleuritis  fibrosa  after  thoracotomy  for  em- 
pyema  must  be  mentioned  here,  also  lumbo- 
abdominal  neuritis,  especially  when  associated 
with  lumbar  herpes  zoster,  likewise  diaphrag- 
matic pleuritis. 

Next  in  order  are  the  diseases  of  the  vertebral 
column.  In  acute  attacks  the  first  thought  will 
be  of  rheumatism  in  the  vertebrae,  often  enough 
the  direct  predecessor  of  articular  rheumatism. 
It  may  also  happen  that  an  acute  attack  of  gout 
primarily  rests  in  the  lumbo-sacral  vertebrae  and 
thus  leads  to  an  erroneous  diagnosis  of  lumbago 


78  GENERALIZED   PAIN 

or  acute  muscular  rheumatism.  A  thorough 
test  of  the  purin  metabolism  is  here  the  most 
potent  factor.  In  chronic  uratic  deathesis  the 
presence  of  pain  in  the  sacrum  seems  to  me 
an  expression  of  gouty  affections  in  the  lumbo- 
sacral  vertebrae.  The  trouble  disappears  under 
antiuratic  treatment. 

Similar  symptoms  are  observed  in  acute  spinal 
meningitis,  in  fact  in  all  infectious  diseases  that 
set  in  with  headache — Acute  rheumatism  is 
frequently  confounded  with  acute  spinal  menin- 
gitis of  tuberculous  origin — A  proper  differen- 
tiation— but  not  in  cerebral  rheumatism — can 
only  result  from  a  consideration  of  those  accom- 
panying symptoms  which  are  foreign  to  acute 
articular  rheumatism,  but  pertain  to  meningitis. 
Both  have  in  common  local  pressure  and  throb- 
bing sensations,  immotility  of  the  spinal  column, 
difficulty  in  sitting  up  or  turning  around,  and 
rise  in  temperature.  But  exclusively  in  menin- 
gitis we  find:  violent  initial  headaches,  hammer- 
ing sensation  in  the  cranium,  turbulent  conditions 
in  the  sensorium,  hyperesthesia  of  the  skin  or  at 
the  trunks  or  extremities  of  the  muscles,  taches 
spinales,  Kernig's  symptom,  indrawn  abdomen, 
and  stubborn  obstipation.  If  only  a  few  of 
these  meningitic  manifestations  are  present,  the 
diagnosis  for  acute  articular  rheumatism  falls. 
That  for  meningitis  will  be  corroborated  by 
lumbar  puncture  and  the  examination  of  the 


SACRUM  79 

fluid  obtained,  which  would  also  definitely  elimi- 
nate the  question  of  cerebral  rheumatism. 

An  epidemic  cerebrospinal  meningitis — not 
tuberculous — might  obscure  the  diagnosis,  but 
a  careful  scrutiny  of  the  symptoms  enumerated 
above  should  easily  dispel  all  doubts. .  We  must 
not  lose  sight,  however,  of  a  possible  early  ap- 
pearance of  very  acute  herpes  in  the  face,  or 
of  an  initial  exanthema,  but  an  examination 
of  the  spinal  fluid,  also  of  the  naso-pharyngeal 
secretions,  should  bring  the  necessary  light.  I 
wish  to  point  out  also  that  in  epidemic  cerebro- 
spinal meningitis  articular  pains  with  or  without 
disfigurations  in  the  articular  outlines  must  claim 
our  attention.  This  is  by  no  means  strange, 
because  epidemic  meningitis  is  a  bacteriemic 
disease  in  its  nature.  The  fact  that  these  articu- 
lar pains  set  in  only  in  the  maturer  and  not  in 
the  earlier  stages  of  the  disease  should  remove 
what  barriers  there  may  be  to  an  adequate  diag- 
nosis. 

During  the  incipient  stages  of  acute  polio- 
myelitis very  intense  lumbar  and  sacral  pains 
beset  the  victim  and  continue  to  hold  sway  dur- 
ing a  goodly  portion  of  the  course  of  the  disease. 
Hyperesthesia  of  the  skin,  differentiation  of  the 
tendon  reflexes  (patellar  reflexes  are  not  pres- 
ent), proclivity  to  perspire  and  leucopenia  are 
telling  points  in  the  diagnosis. 

In  all  cases  in  which  the  patient  complains  of 


80  GENERALIZED   PAIN 

sudden  attacks  of  severe  headache  it  is  our  duty 
to  differentiate  between  the  whole  group  of 
infectious  diseases  that  are  accompanied  by  head- 
ache throughout  the  whole  course.  Tetanus 
belongs  here  when  the  port  of  entry  of  the 
infection,  i.e.,  the  lesion  lies  in  the  sacral  zone. 
Variola,  yellow  fever,  influenza,  grippe,  pseudo- 
influenza,  influenza  nostras  and  exanthematous 
fever  are  further  members  of  this  group.  Yel- 
low fever  is  specially  discussed  in  the  chapter 
on  "Muscular  Pains."  In  exanthematous  fever 
the  pains  in  the  sacrum  are  sometimes  so  aggra- 
vating that  the  patient  can  find  no  resting  place 
in  the  sickbed.  We  can  always  get  a  good 
portrait  of  the  disease  from  the  contemplation 
of  the  following  signs:  chills,  rise  of  tempera- 
ture in  the  continued  fever,  early  acute  splenic 
tumor,  the  xanthic,  dry  coating  of  the  fissured 
tongue,  roseola  spreading  rapidly  over  the  whole 
body,  clouded  sensorium,  leucocytosis,  Weil- 
Felix  reaction,  progressive  changes  of  the  rose- 
ola patches  into  petechiae,  the  decline  of  fever 
between  the  tenth  and  fourteenth  day  of  the  ill- 
ness, and  the  quick  convalescence  of  the  patient. 
In  g astro-intestinal  malignant  pustule  epigas- 
tric as  well  as  lumbo-sacral  pains  are  prevalent. 
The  remaining  symptom  complex  resembles  that 
of  a  generalized  septic  disease  with  repeated 
vomiting,  diarrhea  with  traces  of  blood,  meteor- 
ism,  early  involvement  of  the  circulatory  appa- 


SACRUM  81 

ratus  and  of  the  brain,  and  alarming  dyspnea. 
Bacteriologic  examination  of  the  stools,  of  the 
blood  and  of  the  lumbar  puncture  fluid  and  con- 
sideration of  the  occupational  condition  of  the 
patient  should  warrant  a  correct  diagnosis. 

Variola  (smallpox)  is  always  ushered  in  by 
pains  in  the  sacrum.  An  early  recognition  of 
the  other  symptoms  will  promptly  establish  the 
diagnosis.  I  enumerate  here  the  following: 
initial  vomiting,  headache,  epigastric  pains, 
brisk  rise  in  the  temperature,  symmetric  initial 
exanthema  marked  with  small  hemorrhagic 
lines,  somewhat  resembling  purpura,  generally 
in  the  ilio-femoral  triangle  or  in  the  back,  in  the 
armpit  or  on  the  palate.  All  these  manifesta- 
tions are  of  differential  diagnostic  import,  also 
in  varioloid,  except  that  the  incipient  stages,  the 
whole  course  of  the  disease,  also  the  changes  in 
the  temperature  are  of  a  milder  character,  unless 
the  typical  exanthema  has  already  set  in.  Se- 
vere headaches  are  of  rare  occurrence  in  varicella 
(chickenpox)  a  circumstance  which  distinguishes 
it  sharply  from  variola  and  varioloid. 

Severe  pains  in  the  sacrum  are  more  fre- 
quently found  in  the  plague  than  in  spotted 
typhus. 

The  diagnosis  of  influenza  is  firmly  based  on 
the  evidence  of  articular  pains,  catarrhal  condi- 
tions of  the  mucous  membrane  of  the  respiratory 
tract,  gastrointestinal  symptoms,  tenderness  on 


82  GENERALIZED   PAIN 

pressure  in  the  nasal  cavities  resp.  the  processes 
of  both  the  first  trigeminus  branches,  also  of  the 
occipital  nerves,  the  bacteriologic  findings  of  the 
sputum  and  nasal  secretions. 

Of  very  pronounced  intensity  are  the  pains 
in  the  sacrum  and  along  the  two  ischial  nerves 
in  contagious  or  infectious  erythema.  The  spot 
in  the  face  where  the  affection  appears  feels 
burningly  hot  to  the  touch. 

An  erroneous  diagnosis  of  influenza  may  slip 
in  in  cases  of  trichinosis.  The  patient  complains 
of  lassitude,  gastrointestinal  disturbances  and 
poignant  pains  in  the  sacrum.  Eosinophilia  of 
the  blood,  the  evidence  of  trichinae  in  the  muscles 
and  in  the  blood,  muscular  pains  and  edema  save 
the  diagnosis. 

In  some  infectious  diseases  pains  in  the  sacrum 
do  not  assume  such  a  prominent  position.  I 
include  abdominal  typhoid  and  the  illnesses  due 
to  inoculation  with  anti-typhoid  serum  beginning 
with  chills,  giddiness,  pains  between  the  shoulder 
blades,  behind  the  ribs,  especially  on  the  left 
side  and  also  articular  pains;  paratyphoid,  sep- 
tic and  acute  leucemia,  malaria,  recurrent  fever, 
Weil's  disease,  Malta  fever  and  dengue.  In 
the  latter  there  is  slight  stiffness  in  the  whole 
spinal  column.  This  might  possibly  be  due  to 
impaired  motility  of  the  vertebrae.  In  Malta 
fever  we  might  look  for  a  sympathetic  affection 
of  the  sacro-iliac  vertebrae,  and  in  Weil's  disease 


SACRUM  83 

for  muscular  affection.  The  rest  of  the  acute 
infections  enumerated  above  are  mostly  based 
upon  toxic  infectious  hyperemia  of  the  meninges 
of  the  spinal  cord. 

Of  different  meaning  are  pains  in  the  sacrum, 
with  preference  on  the  right  side  (rather  in  the 
lumbar  region)  in  acute  cystopyelitis,  especially 
during  pregnancy  and  the  lying-in  state,  but 
also  at  other  times  in  the  female  sex.  An  acute 
feverish  illness  coupled  with  sacral  pains  should 
always  prompt  us  to  look  for  a  renal  succussion. 
Bacteriologic,  microscopic,  cultural  and  cytologic 
examination  of  the  urine,  also  when  necessary 
a  cytoscopic  examination,  are  in  demand,  as 
otherwise  the  existence  of  an  acute  pyelitis  might 
be  overlooked.  Of  course,  sacral  pains  may 
also  arise  from  other  affections  of  the  kidneys, 
such  as  renal  tuberculosis.  For  fuller  particu- 
lars consult  my  book  on  "Abdominal  Pain." 

Gonorrhea  likewise  belongs  in  this  category, 
but  only  insofar  as  this  disease  does  establish 
itself  at  times  in  lumbo-sacral  vertebrae.  In 
any  case  of  recent  gonorrhea  the  diagnosis  should 
offer  no  difficulties.  But  in  cases  of  long  stand- 
ing where  the  affection  of  spinal  vertebrae  has 
only  crept  in  by  a  slow  process,  the  diagnosis 

I  ay  meet  with  obstacles.  The  fact  is  that  such 
gonorrhoic  arthritis  may  within  a  given  time, 
perhaps,  during  a  period  of  several  years,  settle 
in  the  zone  of  the  lumbo-sacral  vertebrae,  espe- 


84  GENERALIZED   PAIN 

cially  when  the  latter  have  been  exposed  to 
repeated  traumatic  influences.  In  the  confusion 
a  diagnosis  of  traumatic  neurosis,  vertebral  tu- 
berculosis or  chronic  syphilitic  meningitis  may 
erroneously  result.  Ankylosis  of  the  affected 
vertebrae  in  youthful  individuals  should  always 
be  taken  as  a  very  suspicious  symptom.  Diffuse 
rigidity  in  the  upper  portion  of  the  spinal  col- 
umn is  another  interesting  signal. 

Syphilis  may  also  lead  to  an  analogous  verte- 
bral rigidity.  But  in  this  case  the  entire  spinal 
column  is  involved.  The  classic  therapeutic 
measures  will  promptly  correct  the  malady. 

Rhizomyetic  spondylosis  or  rhizomyeUa  or 
chronic  ankylosing  spondylitis  and  arthritis  de- 
formam  are  concatinated  with  this  series  of 
affections;  arthritis  deformans  especially  when 
coxitis  coexists.  In  both  diseases  the  patient 
complains  sometimes  that  the  pains  appear  after 
he  has  been  standing  upright  or  stooping  down 
for  a  while.  A  change  in  the  weather  may  bring 
them  about.  In  others  they  appear  in  the  morn- 
ing, decline  during  the  day  time  and  during 
rest  vanish  altogether.  There  are  manifestations 
of  neuritis  in  the  roots  (irradiating  pains,  hyper- 
aesthesia,  hyperalgesia,  muscular  irritation  and 
paralytic  manifestations).  In  some  cases  rigid- 
ity in  the  spinal  column,  difficulty  in  walking  or 
when  resuming  an  erect  position  are  the  pre- 
dominent  complaints.  The  clinical  picture  does 


SACRUM  85 

not  often  aid  us  in  differentiating  between  the 
two  diseases,  especially  so  in  the  earlier  stages, 
although  arthritis  deformans  occurs  nearly  always 
only  in  the  later  years  of  man's  life.  The  radio- 
ologist  can  usually  solve  the  question. 

There  is  a  form  of  rigidity  of  the  column  of 
myogenous  origin  in  which  there  is  no  trace  of 
changes  in  the  vertebrae,  but  pregnant  sensi- 
bility to  pressure  and  very  marked  stiffness  and 
atrophy  of  the  muscular  plexus.  The  two  last 
named  signs,  however,  may  also  be  observed  in 
arthrogenous  columnar  rigidity.  I  am  inclined 
to  believe  that  there  is  another  form  of  rigidity 
besides  those  mentioned  here,  viz.,  the  arthro- 
genous form  in  which  no  evidence  of  articular 
changes  appears  on  the  X-ray  plate. 

Pain  in  the  sacrum  is  a  guest  also  in  diseased 
inflammatory  conditions  of  the  sacroiliac  articu- 
lation (synchondrosis) .  The  distinguishing 
marks  are:  the  patient  seeks  relief  by  inclining 
the  body  to  one  side,  there  is  pressure  pain  along 
the  line  of  communication  between  the  sacrum 
and  ilium,  the  painfulness  is  sharpened  under 
bilateral  compression  of  the  pelvis,  or  an  edema 
in  the  sacro-iliac  zone. 

The  pains  arise  from  various  causes.  In 
pregnancy,  in  parturition  they  are  due  to  serious 
infiltration  of  the  joint  ligaments  or  to  merely 
mechanical  influences.  Even  a  quite  normal 
menstruation,  especially  in  mothers,  may  bring 


86  GENERALIZED   PAIN 

about  sacral  pains  during  the  period  through  an 
unusual  relaxation  of  the  sacro-iliac  joints. 
Furthermore,  there  is  a  possibility  of  painful 
spells  in  this  same  joint  in  acute  and  chronic 
articular  rheumatism,  more  rarely  in  gonococcal 
rheumatoids,  but  also  in  infectious  septic  rheuma- 
toids.  But  all  this  happens  chiefly  when  other 
joints  have  been  previously  or  are  simultaneously 
affected.  Then  and  there  it  is  the  primary  or 
else  the  solitary  seat  of  the  articular  affection 
which  may,  however,  also  originate  from  osteo- 
myelitis— not  necessarily  tuberculous.  I  firmly 
believe  that  gout  itself  may  settle  in  the  sacro- 
iliac  joints.  In  Malta  fever  the  pain-stricken 
sacrum  is  the  result  of  an  accompanying  affec- 
tion of  the  sacroiliac  joints.  In  various  static 
conditions  (flatfoot,  pendulous  abdomen)  the 
sacroiliac  joints  are  the  mischievous  element  in- 
sofar as  sacral  pains  are  concerned. 

Diseases  of  the  bony  substance  of  the  verte- 
brae and  of  the  adjoining  ribs  will  provoke 
sacral  pain.  Besides  fractures  of  the  lumbo- 
sacral  vertebrae  (breaking  of  the  5th  lumbar 
vertebra  in  lifting  too  heavy  a  burden,  often  the 
cause  of  pain  for  a  period  of  years)  proved  by 
the  X-ray,  caries,  syphilis,  actinomycosis,  infec- 
tious (paratyphoid)  spondilitis  and  neoplasms 
belong  in  this  place.  Their  diagnosis  will  receive 
proper  attention  in  the  chapter  on  "Backache." 

One  item  of  interest,  however,  I  must  mention 


SACRUM  87 

here,  viz.,  that  pressure  and  pulsation  sensitive- 
ness in  the  spinous  processes  of  the  sacral,  or 
else  of  the  lowest  lumbar  vertebrae  with  pains 
in  the  sacrum,  also  without  any  kind  of  disease 
in  the  vertebrae  themselves,  are  warning  signals 
of  gastro-intestinal  trouble  (rectum,  bladder, 
internal  portion  of  the  genital  organs).  And 
still  another  point  may  be  added:  pain  in  the 
sacrum  is  often  the  register  of  a  carcinoma  meta- 
stasis in  the  lumbo-sacral  vertebrae.  The  pri- 
mary neoplasm  has  not  been  manifest  until  the 
sacral  pain  gives  the  signal  for  a  hunt  of  its 
favorite  habitat  either  in  the  prostate,  the  tes- 
ticles, the  ovaries,  the  mamma,  the  thyroid,  the 
adrenals,  or  in  the  penis  or  the  gastro-intestinal 
canal. 

Diffuse  diseases  of  the  skeletal  frame  fre- 
quently start  with  pains  in  the  sacrum,  especially 
osteomalacia.  The  fact  that  these  pains  arise 
in  the  early  stage  of  the  puerperium,  if  they 
have  not  already  done  so  during  the  latter  period 
of  pregnancy  and  that  they  are  aggravated  by 
walking,  points  to  the  diagnosis  of  osteomalacia, 
especially  when  we  find  the  additional  symptoms 
of  pressure  sensitiveness  in  the  sacrum  or  the 
os  pubis  or  the  ilium — the  latter  is  easily  evinced 
by  a  quick  lateral  compression — the  rostrate  ex- 
tension of  the  symphysis,  the  cordiform  pelvis, 
waddling  gait,  spastic  adduction,  osteoscopic 
pains  (ribs,  sternum),  reduced  stature. 


88  GENERALIZED   PAIN 

The  late  war  has  given  us  copious  proof  of 
the  existence  of  starvation  malacia  of  the  spinal 
column.  There  is  weakness  in  the  legs,  tremor, 
incapacity  for  work  coupled  with  pains,  local 
painfulness,  axillary  compression,  impaired  mo- 
tility  and  a  characteristic  X-ray  picture. 

In  congenital  malformations  of  the  pelvic 
bones  pains  in  the  sacrum  are  of  frequent  occur- 
rence. In  such  cases  radiology  is  the  imperative 
adjuvant  of  the  diagnosis.  It  will  definitely 
reveal  any  abnormal  conditions  that  may  exist 
in  the  bony  lumbo-sacral  column  such  as  spina 
bifida  occulta,  hyperplastic  changes  in  the  trans- 
verse processes  of  the  fifth  lumbar  vertebra 
with  secondary  bursitis  and  contraction  of  the 
last  lumbar  vertebra  with  the  sacrum. 

It  goes  without  saying  that  diseases  of  the 
sacrum  itself  such  as  caries  or  osteomyelitis  carry 
local  pains  with  them,  especially  in  the  softer 
teguments,  e.g.,  bedsores  over  the  os  sacrum. 

The  same  is  the  case  in  affections  of  the  spinal 
cord  and  its  membranes.  In  acute  tuberculous 
or  epidemic  meningitis,  as  has  already  been 
pointed  out,  pain  in  the  sacrum  is  the  foremost 
symptom. 

In  acute  poliomyelitis  there  are  not  only  pains 
in  the  sacrum  but  also  along  the  whole  of  the 
spinal  column.  The  differential  diagnosis  needs 
to  fall  back  in  such  cases  upon  the  other  symp- 
tomatic manifestations  of  meningitis.  Chronic 


SACRUM  89 

spinal  lumbar  meningitis  must  not  be  forgotten 
here.  It  is  not  unlikely  that  the  lancinating 
pains  in  the  sacrum  which  so  frequently  appear 
in  tabes  are  really  due  to  such  a  chronic  menin- 
geal  affection.  Internal  spinal  pachymeningitis 
whether  it  is  hemorrhagic  in  its  nature  or  not, 
and  also  the  syphilitic  form  belong  to  this  order. 
The  exceptionally  intensive  and  often  long  con- 
tinued pains  in  the  sacrum  so  characteristic  of 
membranous  tumors  of  the  spinal  cord  should 
always  remind  us  of  a  possible  morbid  growth 
or  some  other  painful  affection  of  the  cauda 
equina  specially  marked  by  unilateral  pains, 
paresthesias,  pain  in  the  region  of  the  ischiadic 
nerve  and  absence  of  achilles  tendon  reflexes, 
while  in  tumors  of  the  conus  terminalis  distur- 
bances of  sensibility  in  the  ano-vesical  and  sexual 
zones  are  more  prominent. 

In  tumors  of  the  cord  itself  pains  in  general, 
particularly  such  in  the  sacrum  are  rare.  They 
may  be  distinguished  from  extramedullary  pains 
by  the  observation  that  in  extramedullary  tu- 
mors pain  is  the  primary  symptom  and  con- 
tinues to  hold  a  predominating  position  for  a 
long  time.  The  sacral  pains  in  intramedullary 
tumors  are  due  to  secondary  compression  of  the 
neighboring  nerve  roots.  In  true  myelitis  they 
are  of  a  less  vicious  character,  but  if  they  in- 
crease in  acuteness  we  are  warned  of  a  parallel 
meningeal  affection,  i.e.,  meningomyelitis. 


90  GENERALIZED   PAIN 

Syringomyelia  as  well  as  multiple  sclerosis, 
tabes  and  paralysis,  the  paraplegic  (pseudo- 
myelitic)  form  of  hydrophobia  carry  sacral  pains 
as  companions  with  them,  although  they  do  not 
appear  so  vividly  in  the  clinical  picture. 

The  sudden  onset  of  sacro-lumbar  pains  after 
a  trauma  arouses  at  once  the  suspicion  of  an 
injury  to  the  spinal  column,  not  to  speak  of  a 
muscular  breach.  Meningeal  apoplexy,  even 
without  a  preceding  trauma,  is  not  excluded. 
The  patient  usually  cries  out  aloud  with  pain 
and  collapses  as  both  the  lower  extremities  are 
paralyzed.  Hemorrhages  in  the  substance  of 
the  spinal  cord,  acute  hematomyeUa  may  like- 
wise be  the  activating  cause  of  local  lumbar 
sacral  pains,  plainly  due  to  compression  of  the 
adjoining  nerve  roots. 

Functional  nervous  diseases  are  fertile  ground 
for  complaints  of  pains  in  the  sacrum.  Spinal 
irritation,  neurasthenic  muscular  pains  in  the 
back  arouse  the  fear  of  some  kidney  trouble  or 
affection  of  the  spinal  cord  and  promptly  lead 
the  way  to  the  consulting  room.  The  patient 
will  tell  you  that  he  feels  as  if  the  small  of  the 
back  were  broken  in  two,  of  physical  and  mental 
fatigue,  any  kind  of  excitement  provokes  or 
aggravates  the  sacral  pains,  while  on  the  con- 
trary— and  this  is  an  important  symptom — 
moderate  exercise  alleviates  or  banishes  the  pain 
altogether.  Add  to  this  the  proof  that  the  pain 


SACEUM  91 

is  located  in  the  lower  lumbar  zone  or  to  one 
side  of  it,  that  it  radiates  towards  or  along  the 
vertebral  column,  the  constant  change  in  its 
intensity,  the  total  absence  of  other  usual  objec- 
tive symptoms — excepting  the  neurasthenic  signs 
—and  the  diagnosis  should  easily  crystallize. 

The  proper  understanding  of  such  a  condition 
should  largely  influence  our  judgment  that  we 
are  dealing  not  with  an  organic,  but  with  a 
functional  disorder,  e.g.,  of  the  stomach  or  of  the 
heart.  Nevertheless  caution  is  necessary.  In 
sexual  neurasthenia,  for  instance,  the  chief  com- 
plaint is  that  of  pains  in  the  sacrum,  especially 
after  sexual  exercise,  or  after  masturbation  or 
pollution.  Other  complaints  are  strangury, 
mostly  in  the  day  time,  less  so  at  night  (in  some 
cases,  especially  of  long  standing,  there  is  also 
nocturnal  pollakisuria),  subjective  hyperesthesia, 
paresthesia  of  the  external  genitals,  genital  hy- 
perhydrosis,  permanent  feeling  of  cold  feet  due 
to  spermatorrhea  and  nervous  impotence  (in 
persons  of  advanced  age  suspicion  of  incipient 
malignant  neoplasms!),  urethral  or  prostatic 
neuralgia,  orchiodynia  and  similar  manifesta- 
tions. Inadequate  sexual  satisfaction,  excess  in 
venere,  long  continued  coitus  interruptus  are  also 
frequently  the  parents  of  pain  in  the  sacrum. 

In  hysteria  these  pains  are  not  so  common. 
The  diagnosis  here  must  be  based  upon  the 
usual  pertinent  stigmata,  the  presence  of  local 


92  GENERALIZED   PAIN 

hyperesthesia  of  the  skin,  the  fact  that  a  deep 
pressure  often  causes  less  pain,  than  a  soft, 
superficial  touch,  and  the  finding  of  a  similar 
painful  zone  at  a  higher  section  of  the  vertebral 
column,  commonly  situated  between  the  shoulder 
blades. 

Some  psychiatrists  have  reported  cases — I 
have  no  experience  in  this  matter — in  which 
backaches  and  pains  in  the  sacrum  have  been 
of  so  violent  a  character,  that  the  afflicted  per- 
sons were  unable  to  perform  their  vocational 
duties,  sometimes  for  a  year  or  more  during  the 
period  of  adolescence.  This  affliction  has  been 
yclept  "dementia  precox." 

Another  source  of  hieralgia  is  every  form  of 
retroperitoneal  disease.  The  various  renal  and 
adrenal  affections  including  bacteriuria  and  al- 
captonuria  and  all  pancreatic  diseases  are  com- 
prised in  this  classification  because  all  of  them 
father  pains  in  the  sacrum  and  in  the  lumbar 
region.  Splenic  tumors  likewise  belong  here. 
Not  only  the  primary  but  also  the  secondary 
pains  must  be  taken  into  consideration,  for  the 
latter,  radiating  even  into  the  shoulders,  are 
frequently  symptoms  of  an  ulcer  in  the  posterior 
wall  of  the  stomach  or  in  the  duodenum  with 
proliferations  into  the  pancreas,  or  of  an  ulcer 
in  the  pancreas  associated  with  a  gastric  car- 
cinoma, or  perigastritis  which  may  lead  to  an 
arrosion  of  the  pancreas. 


SACRUM  93 

So  far  as  kidney  affections  are  concerned  it 
may  be  said  that  pains  in  the  sacrum  appearing 
on  one,  chiefly  the  right  side  only,  are  often  the 
sole  complaint  in  acute  or  subacute  strangury 
in  pregnant  or  parturient  women.  Fever  and 
renal  succussion  are  not  present  because  there 
is  no  infection  of  the  urinary  apparatus.  Never- 
theless it  is  a  hint  that  these  pains,  although 
primarily  due  to  the  gravid  state,  may  also  arise 
from  a  concomitant  hydroureter.  The  fact  that 
in  these  cases  the  ureter  is  sensitive  on  pressure 
in  the  iliac  region,  should  easily  prevent  the  error 
of  a  mistaken  appendicitis.  This  is  also  true  in 
some  cases  of  chronic  strangury  in  the  male,  for 
instance  in  hypertrophy  of  the  prostate. 

In  affections  of  the  kidneys  (also  of  the  pan- 
creas) the  site  of  the  pain  is  not  always  in  the 
upper  lumbar  region — where  it  anatomically 
belongs — but  apparently  it  is  in  the  lower  lum- 
bosacral  zone.  In  benign  as  well  as  in  malig- 
nant renal  tumors  this  happens  frequently. 

Backaches  in  diseases  of  the  gallbladder,  in 
cholelithiasis,  cholecystitis,  pylorostenosis  and 
duodenal  ulcer  deserve  mention  here.  When 
sacrolumbar  pains  are  present  in  stenosis  of  the 
pylorus  they  are  due  to  a  distension  of  the 
stomach,  unless  they  are  caused  by  a  pyloro— 
or  gastrospasm.  In  this  connection  we  shall 
always  find  a  high  grade  tension  or  flatulent  sen- 


94  GENERALIZED   PAIN 

sation  in  the  epigastrium  which  disappears  with 
spontaneous  or  voluntary  ructus  or  vomiting. 

Duodenal  ulcer,  both  benign  and  malignant, 
is  not  always  of  necessity  associated  with  sacro- 
lumbar  pain.  It  passes  away  often  enough 
without  them  with  the  manifestations  of  a 
chronic  obstructive  icterus  insofar  as  a  carci- 
noma of  the  diverticulum  Vateri  is  concerned. 
But  if  in  the  course  of  the  disease  intensive 
pains  in  the  sacrolumbar  region  suddenly  set  in 
the  diagnosis  of  accessory  retroperitoneal  com- 
plications may  not  be  amiss. 

This  thought  is  quite  opportune  when  such 
pains  turn  up  in  infectious  diseases  of  the  small 
pelvis  which  do  not  by  nature  carry  sacrolumbar 
pains  with  them,  such  as  ascending  phlegmons 
of  the  retroperitoneal  cellular  tissues,  lymphan- 
gitis, retroperitoneal  lymphangitis,  arising  from 
primary  lesions  of  the  internal  female  genitalia, 
or  of  the  rectum  (fissure),  the  internal  male 
generative  organs,  the  external  genitals,  the 
lower  extremities,  and  also  appendicitis,  etc. 
When  tenderness  to  deep  upward  pressure  along 
the  spinal  column  or  arcual  kyphosis  of  the 
lumbar  vertebrae  are  also  in  evidence,  the  diag- 
nosis is  made  easy. 

Neoplasmatic  affections  arising  from  a  new 
growth  in  the  small  pelvis,  e.g.,  a  uterine  carci- 
noma may  be  the  causating  element  of  these 
pains.  In  this  case,  of  course,  not  only  the 


SACEUM  95 

lymphatics   but   also   the  lymph  glands   them- 
selves are  involved. 

Every  disease  of  the  retroperitoneal  lymph 
glands  may  provoke  pains  in  the  sacral  and 
median  region  (see  my  book  on  "Abdominal 
Pain")  for  the  obvious  reason  that  an  enlarged 
gland  naturally  crowds  the  nerve  roots  of  the 
hypogastric  and  lumbar  plexus.  The  glandular 
swellings  may  be  the  outcome  of  tubercular  or 
lympho-granulomatous,  of  leucemic  or  aleucemic 
or  in  rare  instances  of  syphilitic  origin.  Their 
presence  is  betrayed  by  these  very  pains  in  the 
sacrum  as  well  as  by  the  entire  clinical  aspect 
of  the  disease.  Palpation  is  only  possible  when 
a  number  of  the  affected  glands  are  bunched 
together  into  a  lumpy  mass  (tuberculosis,  leu- 
cemia).  We  may  be  also  dealing  with  a  meta- 
static  neoplasm  (sarcoma,  carcinoma  or  a  lym- 
phosarcoma).  In  the  latter  case  the  diagnosis 
will  be  surrounded  by  difficulties  unless  palpa- 
tion is  rendered  possible  for  the  reason  afore- 
said, or  a  splenic  tumor  or  a  lymphosarcomatous 
disease  of  some  other  internal  organ  is  a  con- 
comitant issue  (tonsils,  stomach,  gastrointestinal 
tract).  The  initial  sacral  pains  are  here  a  lead- 
ing symptom,  the  same  as  in  lymphogranuloma 
of  the  retroperitoneal  glands.  In  aleucemia  and 
in  leucemia  these  pains  rarely  manifest  them- 
selves in  the  beginning  of  the  disease,  which  is 
also  the  case  in  chronic  lymphatic  leucemia. 


96  GENERALIZED   PAIN 

The  observation  of  sacro-  or  median-lumbar 
pains  will  prove  a  powerful  adjuvant  in  the 
diagnosis  of  metastatic  growths  in  the  retro- 
peritoneal  (para vertebral)  cellular  tissue  follow- 
ing a  primary  carcinoma  of  the  stomach,  the 
intestine,  the  uterus,  the  esophagus  or  the  mam- 
ma. If  these  pains  arrive  now  in  successive 
attacks  and  then  again  are  of  a  protracted 
character  (not  at  all  uncommon  in  carcinoma  of 
the  stomach)  there  can  be  no  doubt  about  the 
diagnosis.  It  is  further  confirmed  by  a  strong 
pulsation — both  visible  and  palpable  of  the  ab- 
dominal aorta,  and  no  less  by  a  loud  stenotic 
bruit  over  it,  even  noticeable  to  the  touch. 

The  situation  is  different  when  the  gastric 
carcinoma  has  a  rearward  tendency  which  by  its 
very  nature  is  productive  of  sacral  pains,  or  if 
a  companion  sickness  (metastasis)  of  the  spinal 
column  or  an  extension  of  the  carcinoma  itself 
into  the  pancreas  put  in  an  appearance.  In  such 
a  combination,  especially  in  cases  of  direct  arro- 
sion  of  the  pancreas  through  a  gastric  carcinoma 
— likewise  through  an  ulcus  ventriculi  on  the 
posterior  wall  of  the  stomach — the  most  intense 
continuous  pains  are  unleashed  in  the  sacrolum- 
bar  circumference.  (See  "Abdominal  Pain.") 

As  soon  as  the  causative  gastric  disease  is 
recognized  we  shall  promptly  find  the  way  to 
the  companion  affection.  But  whether  the  lat- 
ter is  centered  in  the  lymph  glands  or  in  the 


SACRUM  97 

pancreas  itself  can  only  be  established  by  the 
finding  of  the  other  typical  signs  of  the  pan- 
creatic function,  eventually  by  the  aid  of  the 
X-ray. 

Sacral  pains  in  gastric  carcinoma  may  also  be 
occasioned  by  overloading  of  the  stomach,  thus 
causing  hypertension.  They  may  also  be  a 
diagnostic  roadsign  when  we  waver  between 
carcinoma  of  the  pancreas  and  that  of  the  stom- 
ach, pointing,  perhaps,  with  preference  to  the 
retroperitoneal  space,  i.e.,  the  pancreas. 

In  enlargements  of  the  retroperitoneal  glands, 
also  in  inflammations  thereof,  the  pains  have  the 
same  localization,  but  are  of  lesser  intensity, 
especially  when  retroperitoneal  phlegmons  are  a 
possible  additional  factor,  likewise  morbid  con- 
ditions in  the  small  pelvis  or  infections  of  the 
lower  extremities. 

The  same  kind  of  pains  are  encountered  when 
there  is  an  unusual  strain  on  the  mesenterium 
of  the  peritoneum  at  the  point  of  union  with 
the  lumbar  vertebrae,  e.g.,  in  mesenteric  tumors. 
Likewise,  when  a  tumor  embedded  in  the  mesen- 
terium (metastatic  glandular  tumor)  causes  hy- 
pertension, or  when  a  chronic,  inflammatory 
(tuberculous)  disease  contracts  the  mesenterium. 
Such  conditions  cannot  easily  escape  a  watchful 
eye. 

All  morbid  processes  which  effect  an  acute 
stretching  of  the  mesenterium  are  associated  with 


98  GENERALIZED   PAIN 

median-lumbar  pains  extending  sometimes  even 
upwards  into  the  dorsal  vertebras.  In  cases 
where  we  find  such  sacro-lumbo-dorsal  pains 
associated  with  obstructive  strangulation  our  first 
thought  must  be  directed  to  the  presence  of  an 
intestinal  axial  torsion,  especially  of  the  small 
intestine  or  the  colon.  Aneurysm  of  the  abdom- 
inal aorta  claims  attention  here,  as  well  as  of  the 
aorta  proper,  and  the  entire  venous  system. 
Phlebitis,  or  thrombophlebitis  of  the  iliac  vein 
due  to  inflammation,  suppuration  or  new 
growths  in  the  small  pelvis  or  in  the  lower 
extremities,  may  be  the  originators  of  sacral 
pains  in  one  or  the  other  or  in  both  sides.  Con- 
sidering this  possibility  and  finding  signs  of 
obstruction  in  the  veins  and  their  radicular 
sphere,  a  detailed  diagnosis  should  not  be  diffi- 
cult. It  is  different,  however,  in  cases  of  cellu- 
litis  or  retroperitoneal  lymphadenitis  in  which 
the  symptoms  of  congestion  do  not  prevail. 

Chronic  ectasy  of  the  pelvic  veins  in  women 
is  another  source  of  these  pains,  especially  when 
they  come  to  the  surface  with  the  patient  lying 
down.  The  same  relates  to  thrombosis,  or  throm- 
bophlebitis of  the  pelvic  vessels,  which  are  fre- 
quently the  result  of  inflammatory  or  neoplastic 
affections  of  the  pelvic  organs,  mainly  of  the 
male  or  female  inner  genitalia.  Here  hieral- 
gia  is  often  connected  with  local  pains  in  the 
rectum,  in  the  perineum  and  in  the  buttocks, 


SACRUM  99 

also  in  the  groins.  They  are  aggravated  by 
coughing  or  sneezing,  in  fact  by  every  intra- 
abdominal  pressure. 

In  neuralgia  of  the  celiac  plexus  they  are  a 
partial  factor  only. 

We  may  add  chronic  lead  poisoning,  in  which 
pains  in  the  circumference  of  the  navel  radiating 
into  the  sacrum  and  into  the  thighs  are  notorious. 

Affection  of  distant  organs  may  likewise  be 
provocative  of  pains  in  the  sacrum.  In  women 
they  suggest  morbid  changes  in  the  internal 
sexual  organism. 

During  the  menstrual  period  complains  of 
sacral  pain  are  ripe,  especially  in  pregnant 
women,  primarily  due  to  the  menstrual  moli- 
mena.  In  joint  hysteria  the  pains  are  often  of 
a  most  distressing,  excruciating  character,  espe- 
cially when  there  is  a  slight  uterine  retroflexion 
or  a  congenital  narrowing  of  the  os  or  cervix 
uteri.  If  the  retroflexion  is  very  pronounced 
the  pains  are  continuous. 

Sacralgia  often  plays  a  part  in  the  climacteric 
process,  and  is  caused  by  the  contraction  of  the 
pelvic  connective  tissue.  We  meet  here  vaso- 
motoric  disturbances,  heat  flushes,  congestion  in 
the  head,  spontaneous  perspiration,  paresthesia 
in  the  arms  and  legs,  bluish  tint  and  coldness 
of  the  fingers,  palpitation,  cardiac  pains,  adipos- 
ity, meteorism,  Heberden's  nodules,  and  pains 
in  the  nerves  and  bones. 


100  GENERALIZED   PAIN 

There  is  a  goodly  number  of  diseases  of  the 
female  genital  organs  which  travel  together  with 
sacral  pains.  If  of  a  very  distressing  character 
they  speak  for  some  endometric  affection,  spe- 
cifically uterine  colics.  Labor  pains  affect  the 
sacrum  in  like  manner,  and  so  does  the  accumu- 
lation of  blood-clots  in  uterine  hemorrhages.  We 
find  these  pains  also  in  affections  of  the  walls  of 
the  uterus  and  of  the  adnexa,  in  parametritis 
and  perimetritis  of  acute  or  chronic  duration,  in 
descent  or  prolapse  of  the  womb,  in  new  growths 
of  the  uterus  and  of  the  ovaries  and  in  retro- 
uterine  hematocele. 

It  is  evident  that  the  presence  of  sacral  pains 
in  one  and  the  same  gynecological  disease  may 
be  due  to  quite  a  number  of  different  causes, 
for  instance  in  carcinoma  of  the  uterus.  There 
might  be  a  carcinomatous  infiltration  of  the 
pelvic  connective  tissue  reaching  up  even  into 
the  retroperitoneal  cellular  tissue,  or  there  might 
be  a  metastasis  of  the  retroperitoneal  glands  or 
in  the  field  of  the  sacral  vertebras,  or  else  hemor- 
rhages in  the  uterine  cavity,  all  quite  indepen- 
dent of  the  primary  uterine  ailment. 

I  should  like  to  give  mention  in  this  place 
to  a  particular  kind  of  sacralgia  which  occurs 
in  women  who  wear  lingerie  which  is  open  in 
the  groins,  and  in  consequence  take  cold  locally 
in  semblance  of  a  rheumatic  affection.  The 
symptoms  are  easily  recognized,  viz.,  the  pains 


SACRUM  101 

are  strongly  influenced  by  chilly,  damp  weather, 
brisk  physical  exercise,  by  running,  jumping  or 
stooping,  and  there  is  delicacy  to  touch  and 
pressure  in  the  dorsal  muscles  and  the  spinal 
joints. 

Coitus  interruptus  is  another  cause  of  sacral- 
gia  in  the  female.  We  hear  complaints  of  a 
dragging  downward  sensation,  strangury  and 
general  nervousness,  no  doubt  due  to  a  deficient 
detumescence  of  a  congested  uterus  during  the 
sexual  act. 

In  prostatitis,  carcinoma  of  the  prostate  and 
tuberculosis  and  other  affections  of  the  male 
genital  organs,  sacralgia  is  of  rare  occurrence. 
I  refer  to  this  on  purpose  in  order  to  forestall 
a  mistaken  diagnosis  of  kidney  trouble. 

The  rectum  is  very  extensively  responsible 
for  sacral  pains.  Hemorrhoids  are  the  princi- 
pal offenders.  Copious  bleeding  from  piles 
often  removes  the  pains  from  the  sacrum,  at  any 
rate  for  a  time.  Nevertheless,  a  thorough  ex- 
amination of  the  rectum  for  a  possible  fissure 
or  carcinoma  should  be  made  in  every  case. 

Polypus  may  also  give  rise  to  rectal  hemor- 
rhages and  pains  in  the  sacrum.  Rectoscopy 
is  here  in  order. 

Affections  of  the  colon,  especially  a  deep- 
seated  carcinoma,  have  similar  effects  on  the 
sacral  zone.  Complaints  about  aches  in  this  re- 
gion often  reach  us  when  there  is  difficulty  in 


102  GENERALIZED   PAIN 

getting  rid  of  intestinal  gases,  in  cases  of 
chronic  constipation,  or  obstruction  in  the  rectal 
passage,  also  disturbances  in  the  intestinal  cir- 
culation or  chronic  intestinal  catarrh. 

When  a  carcinoma  of  the  rectum  has  been 
positively  diagnosed,  our  next  thought  must  be 
directed  to  every  possible  form  of  deep-seated 
intestinal  stenosis.  Distension  and  wind  in  that 
part  of  the  colon  which  lies  beyond  the  stenosis 
generate  pains  in  the  sacrum,  which  eventually 
are  modified  or  cleared  away,  for  a  period  at 
any  rate,  by  a  copious  alvine  evacuation,  or  even 
a  satisfactory  flatus. 

Pellagra  is  another  fertile  cause  of  sacral 
pains  and  backache.  Its  diagnosis  is  easy,  for 
the  following  reasons:  its  prevalence  is  limited 
apparently  to  those  countries  in  which  maize  is 
a  staple  article  of  food.  It  occurs  in  the  spring 
or  the  autumn,  it  shows  atypical  erythema,  there 
are  characteristic  manifestations  in  the  oral  and 
genital  mucous  membrane,  there  are  digestive 
as  well  as  psychic  disturbances,  and  pronounced 
emaciation. 


Pain  in  the  Buttocks 

If  a  patient  complains  of  pains  in  the  coccy- 
geal  region,  we  generally  have  before  us  a  trau- 
matic surgical  disease  (a  birth  or  a  fall).  It 
may  be  a  periostitis,  a  subluxation,  or  a  luxation 
of  the  coccyx  against  the  sacrum,  or  a  fracture, 
or  tuberculous  caries  or  osteomalacia.  If  exam- 
ination per  rectum  and  the  X-rays  prove  the 
absence  of  all  these  affections,  and  if  we  are 
satisfied  that  no  rectal  disorders  (fissure,  fistula, 
neoplasm)  or  genital  or  pelvic  defects  that  might 
be  mistaken  for  coccygodynia,  are  present,  we 
are  still  confronted  by  disturbances  which  may 
be  causative  factors  of  pains  in  the  nates. 

There  is  the  possibility  of  neuralgia  of  the 
coccygeal  plexus,  frequently  a  sequel  of  mastur- 
bation, sometimes  the  expression  of  a  sexual 
neurasthenia,  or  in  rare  cases  the  manifesta- 
tion of  gouty  diathesis.  I  have  seen  two  cases 
of  coccygodynia  in  men — it  occurs  in  women 
with  greater  frequency — which  were  indubitably 
accompanied  by  chronic  gouty  diathesis.  Both 
diseases  yielded  promptly  to  therapeutic  meas- 
ures. Coccygodynia  in  the  climacteric  period 
may,  perhaps,  be  explained  in  this  manner. 
On  the  other  hand,  we  come  across  cases  in 

103 


104  GENERALIZED  PAIN 

women  in  which  this  disease  of  the  coccyx  is 
only  a  partial  manifestation  of  a  generalized 
hysteria. 

Besides  tenderness  to  pressure  of  an  other- 
wise quite  normal  coccyx  and  localized  cutaneous 
hyperesthesia,  we  are  bound  to  discover  other 
signs  of  hysteria,  and  as  the  causative  element 
an  acute  psychic  trauma  with  the  elimination  of 
which  both  coccygodynia  and  hysteria  vanish.  Of 
course,  we  find  in  non-complicated  hysteria  also 
pain  and  delicacy  to  touch,  also  cutaneous  hy- 
peralgesia  in  the  coccygeal  region  as  well  as  in 
the  sacrum,  with  deep  pains  in  the  pelvis  radi- 
ating into  the  corresponding  vertebral  sur- 
roundings. 

In  females,  coccygodynia  is  frequently  more 
a  part  of  neurasthenia,  or  a  spinal  irritation. 
Here,  too,  we  find  the  paradoxical  condition 
that  the  soft  touch  awakens  the  pain,  whilst  a 
slowly  ascending,  long-continued  pressure  gives 
relief.  Hot  sponging  or  a  weak  electric  current 
may  prove  very  painful.  Local  and  generalized 
vasomotoric  manifestations  are  not  uncommon 
companions  of  pains  in  the  breech.  High  feed- 
ing and  psychic  influences  are  apt  to  remove 
the  complaint  for  good. 

Finally,  coccygodynia  may  be  a  partial  symp- 
tom of  tabes  dorsalis  or  the  direct  result  of 
flat  foot. 


Pain  in  the  Shoulder 

The  term  employed  here  bears  a  double  mean- 
ing, viz.,  pain  in  the  shoulder  proper  and  pain 
between  the  shoulder  blades,  i.e.,  between  the 
scapula  and  the  spinal  column  or  in  the  spinal 
column  itself  or  in  the  acromion.  Pains  in  the 
supraclavicular  and  supraspinous  fossa  natu- 
rally are  included. 

Pains  in  the  scapular  region  conjure  up 
thoughts  of  all  kinds  of  affections  of  the  shoul- 
der joint.  (Many  particulars  regarding  this 
matter  will  be  found  in  the  chapter,  "Pains  in 
the  Joints.")  In  many  morbid  articular  con- 
ditions the  shoulder  joint  is,  as  a  rule,  the  only 
member  to  be  considered,  if  not  throughout, 
at  any  rate  for  a  notable  period  of  the  malady's 
course.  Traumatic  and  neurotic  affections,  pye- 
mic  metastasis  localized  exclusively  in  the  shoul- 
der joint,  gonorrhea  and  syphilis,  all  are  possi- 
bilities. But  in  the  front  rank  I  mention  the 
various  forms  of  arthritis,  from  acute  to  chronic 
deforming  omarthritis,  and  gout  in  the  sense  of 
omagra. 

The  diagnosis  is  built  up  from  the  following 
symptoms:  seat  of  the  pain,  restricted  motility 
of  the  joint,  especially  in  an  upward  and  back- 

105 


106  GENERALIZED   PAIN 

ward  direction,  the  contrast  between  the  rela- 
tively free  active  motility  and  the  pain  caused 
by  a  jerky  movement  of  the  joint  by  the  phy- 
sician, sensitiveness  on  pressure  or  percussion, 
especially  at  the  articular  extremity;  changes  in 
the  articular  outlines,  the  assistance  of  the 
Roentgen  ray.  For  a  more  detailed  diagnosis, 
I  refer  the  reader  again  to  the  chapter  on 
"Articular  Pains." 

The  shoulder  joint  may  also  be  the  seat  of 
arthropathy,  especially  in  syringomyelia.  Very 
severe  pain  may  be  a  reflex  of  a  spinal  affection, 
e.g.,  multiple  sclerosis. 

When  a  patient  speaks  of  pains  in  the  shoul- 
der or  in  the  region  of  the  shoulder  joint,  it  is 
not  unwise  to  think  of  a  different  derivation. 
In  acute  febrile  conditions  the  nearest  point  must 
needs  be  an  acute  osteomyelitis  in  the  upper 
arm. 

A  chronic  inflammation  (tuberculosis)  or  a 
neoplasm  in  the  osseous  substance,  the  humerus, 
will  always  prove  to  be  painful  conditions,  and 
really  belong  in  the  operating  room.  The  in- 
ternist is  more  interested  in  secondary  metastatic 
new  growths  of  the  scapular  bones.  Many's 
the  time  that  a  patient  complains  about  "rheu- 
matic" pains  in  the  shoulder,  bothersome  today, 
missing  tomorrow,  coming  on  again  the  next 
day,  and  is  treated  by  his  doctor  for  rheumatism, 
when  a  closer  examination  reveals  a  primary 


SHOULDER  107 

malignant  neoplasm  (prostate,  ovary,  testicle, 
mamma,  thyreoid,  hypernephroma),  and  the 
local  conditions  (pressure  and  throbbing  pains, 
X-rays),  also  blood  test,  leave  no  doubt  of  the 
existence  of  a  metastasis  of  the  bones.  (See 
chapter  on  "Pains  in  the  Bones.") 

An  acute  painful  affection  of  the  muscular 
plexus  of  the  shoulder  joint,  of  the  deltoid,  or 
of  the  scapular,  cucullar,  pectoral  muscles,  an 
acute  scapular  myalgia  or  omalgia  may  very 
well  give  ground  to  complaints  of  shoulder 
pains,  in  which  condition  the  sick  seek  relief  by 
keeping  this  articulation  as  quiet  as  possible. 
These  pains  are  in  reality  caused,  as  a  rule,  by 
overburdening  or  overtaxing  the  muscles,  e,g., 
in  amateur  sportsmen,  carrying  a  heavy  valise 
or  wearing  a  heavy  overcoat,  etc.  The  fact  that 
in  these  cases — not  to  speak  of  a  Roentgen 
photograph  of  the  affected  joint — the  muscles 
are  very  tender  on  pressure,  should  make  the 
diagnosis  easy.  When  the  pains,  however,  ra- 
diate into  the  forearm,  waist  or  even  the  fingers, 
a  neuritic  condition  might  be  a  good  guess. 
But  the  lack  of  the  other  classic  neuritic  mani- 
festations (sensibility  disturbances,  tenderness  on 
pressure  in  the  nerves,  nodules,  vasomotoric  and 
trophic  derangements)  should  be  a  decisive 
factor. 

In  a  similar  fashion,  bracJual  neuritis  is  in 
error  often  taken  for  omarthritis.  This  is  quite 


108  GENERALIZED   PAIN 

excusable  because  a  primary,  inflammatory 
articular  affection  is  frequently  accompanied  by 
secondary  neuritic  conditions  of  the  nerves  which 
encompass  or  pass  over  the  articulation.  In 
this  case  the  pains  radiate  along  the  correspond- 
ing nerve  trunks  and  give  rise  to  paresthesias 
in  the  affected  zone.  On  the  other  hand,  there 
may  be  an  atrophy  of  the  appertaining  muscles, 
but  without  sensibility  disturbance  and  without 
denegeration  of  the  electric  reaction,  the  latter 
being  only  minimized.  Some  authors  attribute 
this  muscular  atrophy  to  a  functional  lesion  of 
the  ganglion  of  the  anterior  columna. 

The  presence  of  actual  neuritic  changes  may 
seriously  handicap  a  concrete  diagnosis,  because 
the  patient  experiences,  when  moving  the  upper 
arm,  identically  the  same  intense  pains  as  if 
the  joint  itself  were  affected.  The  differential 
diagnosis  between  neuritis  on  the  one  hand  and 
omarthritis  on  the  other  may  in  consequence  be 
gravely  influenced.  In  favor  of  neuritis  speak 
the  following  facts:  the  joint  itself  is  not  the 
most  sensitive  part,  pressure  upon  it  from  any 
direction  does  not  materially  exacerbate  the 
pain,  which  is  rather  localized  in  the  nerve 
trunks  and  in  the  muscles  of  the  upper  arm, 
the  presence  of  paresthesias,  sensibility  distur- 
bances and  muscular,  truly  neuritic,  atrophies. 
But  even  this  consideration  will  leave  us  in 
perplexity  if  both  anarthritis  and  neuritis  run 


SHOULDER  109 

a  joined  course.  Yet  if  the  anamnesis  estab- 
lishes the  fact  that  the  articular  affection  came 
first  and  the  neuritic  conditions  only  as  second- 
ary manifestations,  then  Roentgen  photography 
will  promptly  make  the  differential  diagnosis 
positive. 

On  the  other  hand,  there  are  patients  who 
locate  the  pain  not  only  in  the  shoulder,  but 
ako  in  the  nape  of  the  neck,  or  in  the  upper 
arm  alone,  or  again  in  the  whole  arm  from  the 
apex  of  the  shoulder  down  to  the  very  finger- 
tips, and  these  pains  are  aggravated  with  every 
movement.  We  find  the  nerve  trunks  hyper- 
sensitive on  pressure,  also  exaggerated  tender- 
ness of  the  skin,  muscles  and  bones,  but  no  dis- 
turbances of  sensibility  or  noteworthy  muscular 
atrophy.  A  great  temptation,  indeed,  to  attrib- 
ute the  cause  of  the  pains  to  neuritis.  And  yet 
there  is  anarthritis  with  secondary  brachialgia. 
The  diagnosis  is  based  here  on  the  X-ray  and 
another  point  of  great  moment,  viz.,  if  we  find 
that  pressure  upon  the  shoulder  joint,  especially 
forward  in  the  intertubercular  sulcus,  is  par- 
ticularly painful,  we  have  definite  proof  that  the 
motility  of  the  shoulder  joint  is  essentially  im- 
paired. The  head  of  the  humerus  is  firmly  set 
in  the  joint  by  muscular  contraction  so  that  the 
joint  can  no  longer  be  moved  by  fixation  of  the 
scapula.  Otherwise  the  scapula  will  involuntar- 
ily follow  every  passive  movement  of  the  arm, 


110  GENERALIZED   PAIN 

giving  the  patient  intense  pains  as  far  down 
as  the  fingers.  In  this  fixation  of  the  upper 
arm  we  have  a  definite  proof  of  an  existing 
primary  arthritis. 

And  yet  there  are  patients  who,  contrariwise, 
locate  the  pain  in  the  shoulder  blade  when  it 
really  is  in  the  cervicobrachial  plexus.  It  will 
occur  in  restricted  morbid  conditions  of  the 
supraclavicular  fossa,  e.g.,  of  the  superior  pul- 
monary lobe  (tuberculosis,  tumors,  glandular 
swellings),  also  of  the  mediastinum,  with  direct 
or  irradiating  stimulation  of  the  appropriate 
nerve  plexus.  The  diagnosis  is  simple  enough, 
for  the  reason  that  careful  probing  reveals  a 
strong  sensitiveness  to  pressure  in  the  plexus 
above  the  clavicle,  whilst  there  is  no  such  reac- 
tion in  the  joint  itself. 

Sometimes  an  articular  affection  seems  to 
exist,  when  in  reality  the  pains  are  due  to  an 
inflammatory  process  in  a  synovial  sac,  chiefly 
behind  the  deltoid,  especially  in  resorption  of 
tuberculous  pleural  exudates.  The  diagnosis  in 
this  case  is  beset  with  great  difficulties  when 
coarser  configuration  anomalies  are  lacking.  If 
there  is  no  pressure  pain  anteriorly  between  the 
acromion  and  the  coracoid  process,  and  also  in 
the  direction  of  the  axilla,  if  the  shoulder  joint 
moves  freely,  if  there  is  only  localized  tenderness 
in  the  upper  arm  about  three  inches  below  the 
acromium,  a  visible  swelling  in  the  bicepital 


SHOULDER  HI 

sulcus,  pronounced  reactionary  inhibition,  and 
distressing  painfulness  when  the  patient  is  abed 
or  resting,  the  chances  are  that  we  are  dealing 
with  a  case  of  bursitis.  A  test  for  narcosis  is 
indicated  when  the  morbid  condition  is  of  long 
standing.  Free  articular  motility  should  here 
also  point  to  bursitis.  The  X-ray  picture  will 
be  of  service. 

A  subpectoral  phlegmon  will  claim  our  atten- 
tion when  we  find  upon  closer  scrutiny  a  digital 
lesion,  high  fever,  malaise,  septic  conditions,  a 
feeling  of  tension  when  the  arm  is  moved,  or 
else  lymphangitis  and  lymphadenitis. 

Pains  in  the  shoulder  radiating  into  the  upper 
extremity  are  in  all  probability  of  arterial  ori- 
gin; a  surmise  of  intermittent  dyspragia  arising 
from  arteriosclerosis  or  arteritis  is  here  a  safe 
conductor.  The  deciding  factor  is  that  the  pain 
sets  in  with  the  movement  of  the  arm  and  ceases 
when  the  member  is  at  rest.  But  it  may  also 
come  on  on  a  march  or  during  a  brisk  walk, 
only  to  disappear  again  when  a  halt  is  made. 
Evanescence  of  the  arterial  pulse  and  the  Roent- 
genogram  are  typical  proofs  of  this  painful 
affection,  which  is,  however,  sometimes  also 
recognized  in  the  lower  extremities. 

Retrosternal  pains  in  the  chest  that  radiate 
into  the  apex  of  the  shoulder  and  thence  into 
the  arm,  nape  of  the  neck,  and  with  preference 
into  the  left  lower  jaw,  intimate  an  existing 


112  GENERALIZED   PAIN 

angina  pectoris  or  aortalgia,  even  though  this 
irradiation  does  not  in  all  cases  extend  beyond 
the  shoulder.  It  may  likewise  take  the  direction 
of  the  right  instead  of  the  left  shoulder. 

Pains  in  the  shoulder  associated  with  aches  in 
the  back  and  sacrum  are  often  of  "psychoge- 
nous"  origin  in  such  diseases  as  hysteria,  neu- 
rasthenia, and  psychopathies.  The  diagnosis  in 
these  cases  may  be  at  times  somewhat  puzzling, 
particularly  when  the  patient  attributes  the  pain 
to  a  cold,  or  an  overexertion  or  an  unexpected 
drenching.  Negative  clinical  findings,  proper 
consideration  of  the  general  physical  conditions 
and  radiology  should  grant  a  satisfactory  so- 
lution. 

Rheumatic  pains  in  the  shoulder  may  be  irra- 
diations of  nervous  origin,  f.i.,  (of  the  phrenic 
nerve,  and  extend  from  the  abdominal  region  as 
far  as  the  cervical  nerves.  If  the  pains  are  in 
the  right  shoulder  (or  both)  we  should  be  re- 
minded of  rupture  of  the  liver,  cholelithiasis, 
abscess,  gumma,  tuberculosis  of  the  liver;  if  in 
the  left  shoulder  (or  both),  rupture  of  the  stom- 
ach, ulcus  ventriculi  with  or  without  perigas- 
tritis,  a  ventricular  carcinoma  in  the  pyloric  re- 
gion, or  rupture  of  the  duodenum  as  a  sequel 
to  duodenal  ulcer,  even  of  the  stomach  due  to 
a  parapyloric  ulcer,  or  of  the  jejunum  after  a 
peptic  ulcer  thereof.  Furthermore,  we  may  ex- 
pect affections  of  the  left  hepatic  lobe  (gumma, 


SHOULDER 

carcinoma),  with  perigastritis,  or  splenic  dis- 
eases, e.g.,  perisplenitis,  splenic  infarcts  or  ab- 
scesses, or  rupture  or  echinococcus  of  the  spleen, 
or  myelogenous  leucemia,  paranephritic  abscess 
or  an  acute  pancreatic  affection  (acute  pancrea- 
titis, necrosis  of  the  pancreas)  (left  shoulder). 
In  retroperitoneal  growths  of  the  retroperitoneal 
cellular  tissue  (glandular  metastases,  acute  in- 
flammation, calosities,  metastatic  neoplastic  in- 
filtrations) they  appear  mostly  on  the  left  side, 
likewise  in  all  possible  neoplasms  within  the 
retromediastinal  space,  not  to  forget  hemor- 
rhages flooding  the  peritoneal  cavity  below  the 
diaphragm  (tubal  pregnancy). 

Naturally  the  patient  complains  of  pain  in 
the  affected  part  ranging  as  far  as  the  shoulder. 
But  he  exhibits  also  other  local  signs,  e.g.,  local- 
ized tension  of  the  abdominal  muscles  (rupture 
of  the  stomach,  of  the  duodenum,  etc.),  absence 
of  abdominal  breathing  or  increased  pain  during 
the  act.  Coughing  or  walking  aggravate  these 
pains,  which  also  possess  the  peculiarity  that 
local  pressure  over  the  seat  of  the  tumor  influ- 
ences more  the  pain  in  the  shoulder  than  that  in 
the  abdomen.  But  I  make  the  point  that  a 
ventricular  ulcer  or  carcinoma  will  throw  the 
pains  to  the  right  shoulder,  when  it  and  the 
liver  have  grown  together;  likewise,  that  shoul- 
der pains  in  appendicitis  indicate  a  high  location 
of  the  vermiform  appendix  or  an  upward  ex- 


114  GENERALIZED   PAIN 

tension  of  the  morbid  condition,  i.e.,  towards  the 
liver  or  diaphragm.  Sometimes  this  shoulder 
pain  is  still  further  marked  by  the  circumstance 
that  it  is  very  much  aggravated  when  the  right 
leg  is  somewhat  overstretched  in  the  hip  joint. 

In  affections  of  the  pleura  (pleuritis)  or  con- 
tractions of  the  phrenico-costal  sinus,  in  empy- 
ema,  pneumothorax,  in  severances  of  pleural 
adhesions,  affections  of  the  lungs  or  pericardium, 
these  self -same  irradiating  shoulder  pains  are 
very  annoying,  just  as  they  are  in  an  artificial 
pneumothorax  or  a  sudden  hemorrhage  in  the 
pleural  cavity  from,  for  instance,  a  ruptured 
aortic  aneurysm. 

I  wish  to  lay  emphasis  on  the  fact  that  when 
the  patient  complains  exclusively  of  shoulder 
pain,  the  seat  of  the  trouble  is  for  a  certainty 
to  be  found  in  the  liver.  There  are  two  possi- 
bilities: Uver  abscess  following  amebic  dysen- 
tery, but  after  a  long  interval,  echinococcus  of 
the  liver.  The  enlargement  of  the  liver — proved 
by  pain  upon  lateral  pressure  against  the  hypo- 
chondria— the  presence  of  a  cystic  bulging  of 
the  liver  towards  the  lung,  and  other  individual 
symptoms  (color  of  the  face,  attitude  of  the 
patient,  leucocytosis,  rise  in  temperature)  and 
the  anamnesis  should  definitely  settle  the  diag- 
nosis of  hepatic  abscess, 

We  must  always  think  of  that  when  the  sick 
man  who  has  had  dysentery  or  any  other  in- 


SHOULDER 

flammatory  or  suppurative  process  in  the  radicu- 
lar  area  of  the  portal  vein,  begins  to  worry 
about  pains  in  the  right  shoulder.  In  echinococ- 
cus  there  is  pain  in  the  right  shoulder  only  when 
the  parasite  is  embedded  immediately  under  the 
diaphragm.  In  this  case  there  is  also  a  domelike 
axillary  bulging  upwards  of  the  diaphragm. 
With  the  aid  of  the  other  characteristic  symp- 
toms of  this  cystic  parasite  and  of  subdiaphrag- 

latic  liver  abscess,   especially  the  X-ray,   the 
>roper  diagnosis  cannot  be  missed. 

Sarcoma  of  the  liver  is  likewise  associated 
with  pains  in  the  right  shoulder.  This  affection 
forms  one  or  more  nodes  on  the  surface  of  the 
liver  which  arch  the  diaphragm  upwards.  So 
long  as  there  is  no  dullness  of  sound  over  this 

rch,  a  diagnosis  of  hepatic  carcinoma  can  only 
)e  made  when  we  find  also  in  other  parts  of  the 
liver  carcinomatous  eminences  which  change  the 

lape  of  this  organ  so  far  as  it  is  accessible  to 
the  touch.  Our  suspicion  should  be  aroused 

rhen  an  elderly  cachectic  patient  complains  of 
pains  in  the  right  shoulder,  although  we  can 
find  no  pathological  changes  either  here  or  in 
the  vicinity  (neck,  lung,  mediastinum). 

Febrile  gummata  of  the  liver,  associated  with 
cholelithiasiform,  intensive,  colicky  attacks,  gen- 
erally start  with  severe  pains  in  the  right  shoul- 
der several  days  in  advance  of  the  colicky  spells, 
run  a  parallel  course,  and  disappear  with  them. 


116  GENERALIZED   PAIN 

Cholelithiasis  itself  does  not,  as  a  rule,  bring 
these  pains  in  the  right  shoulder  with  it;  but  I 
once  saw  a  case  in  which  this  did  happen,  with 
the  result  of  an  erroneous  diagnosis  of  neuritis. 

In  perihepatitis  in  those  parts  which  incline 
toward  the  diaphragm  the  same  pains  may  be 
expected,  and  we  must  keep  a  sharp  lookout 
for  other  morbid  processes  in  the  diaphragm 
from  which  pains  might  travel  via  the  phrenic 
and  by  transmission  to  the  fourth  cervical  nerve, 
and  thence  to  the  cutaneous  nerves  of  the 
shoulder. 

In  subphremc  abscesses  this  happens  princi- 
pally when  the  subphrenic  suppuration  proceeds 
from  the  liver  or  the  spleen. 

More  often  is  it  advisable  to  think  of  dia- 
phragmatic pleuritis  when  these  shoulder  pains 
have  come  suddenly  to  the  surface  and  have 
continued  for  days  as  the  most  prominent  mor- 
bid symptom.  The  diagnosis  may  safely  lean 
here  upon  the  other  well-known  signs  of  pleu- 
ritis, which,  by  the  way,  may  also  harbor  a 
primary  subpleural  tubercular  condition  of  the 
lung. 

Diaphragmatic  hernias  and  eventration  are 
the  homes  of  pain  that  radiates  from  the  chest 
to  the  shoulder,  a  sign  of  diagnostic  value  espe- 
cially when  also  the  stomach  has  passed  through 
the  hernial  breach  in  the  pectoral  space.  With 


SHOULDEB  117 

the  intake  of  food  the  pains  are  naturally  very 
much  exacerbated. 

But  shoulder  pain  may  be  the  only  and  ex- 
clusive complaint  in  any  form  of  pleuritis  which 
leads  to  an  irritation  of  the  phrenic  nerve.  It 
has  even  the  peculiar  habit  of  becoming  more 
severe  with  any  movement  of  the  right  shoulder 
joint,  thus  leading  to  a  false  diagnosis  of  om- 
arthritis.  The  presence  of  phrenic  pressure 
points  (those  in  the  neck,  sternum  and  spinal 
column  may  miss  and  only  the  abdominal  points 
may  react!),  the  non-participation  of  the  af- 
fected thoracic  portion  in  the  act  of  breathing 
and  the  accelerated  respiration  will  no  doubt 
facilitate  the  diagnosis  even  when  no  pleural 
friction  is  perceptible. 

The  same  applies  to  pericarditis  and  medias- 
tinitis. 

Of  course,  shoulder  pains  are  always  a  sign 
of  any  possible  irritation  of  the  phrenic  nerve, 
also  of  foreign  bodies  in  the  diaphragm  itself — 
even  a  projectile — often  associated  with  hic- 
cough. 

In  splenic  affections,  e.g.,  perisplenitis,  domi- 
nating pains  in  the  left  shoulder  make  the  ab- 
dominal hypochrondral  pains  of  secondary  con- 
sideration to  such  an  extent  that  the  patient  only 
complains  of  the  former.  This  often  leads  to  a 
mistaken  diagnosis  of  rheumatism  of  the  shoul- 
der joint. 


118  GENERALIZED   PAIN 

When  we  can  find  no  clinical  or  radiologic 
evidence  of  changes  or  motoric  defects  in  the 
joint,  nor  typical  pressure  points,  but  hepatic 
or  lienic  hyperesthesia  of  the  skin  or  tenderness 
iii  the  trapezius  region  and  respiratory  differ- 
ences, we  must  look  for  other  abdominal  symp- 
toms if  we  wish  to  find  the  correct  diagnosis. 

In  rare  cases  only  exclusive  pains  in  the 
shoulder  are  a  sign  of  nephrolithiasis.  The  lum- 
bar and  hypochondral  pains,  however,  some- 
times radiate  as  far  as  the  scapula.  Only  long 
experience  will  prevent  mistakes  in  these  cases. 

It  will  be  seen  that  in  most  of  the  cases 
quoted  here  tenderness  in  the  trapezius  muscle 
is  a  usable  diagnostic  sign.  I  will  mention  here 
that  this  delicacy  is  often  the  only  available 
symptom,  shoulder  pain  being  absent,  and  that 
its  discovery  is  an  essential  advantage  for  the 
diagnosis  of  the  subdiaphragmatic  organic  dis- 
eases in  question. 

In  all  these  diseases  the  shoulder  pain,  whether 
it  is  isolated  or  irradiated,  emanates  beyond 
from  the  phrenic  nerve  through  a  symptomatic 
neuritis  (neuralgia)  thereof. 

Insofar  as  idiopathic  neuralgia  of  the  phrenic 
nerve  is  concerned,  I  speak  with  reserve. 


In  another  chain  of  cases  the  patient  does  not 
point  to  the  shoulder  joint  or  the  space  between 
the  shoulder  blades,  but  rather  to  that  part 


SHOULDEB 

of  the  back  which  is  occupied  by  the  scapula 

as  the  seat  of  pain.  Cholelithiasis,  for  instance, 
when  associated  with  an  ulcer,  irradiates  its 
pain  into  or  against  the  shoulder  blade,  or  else 
between  the  two  blades. 

Sometimes  the  movement  of  the  scapula  is 
accompanied  by  a  harsh,  crackling  sound  which 
is  noticeable  to  the  patient  as  well  as  to  the 
bystander.  This  noise  is  apparently  due  to  the 
formation  of  an  accessory  synovial  sac  and  a 
proliferating  hygroma  within  it  between  the 
anterior  scapular  plane  and  the  posterior  thoracic 
wall,  or,  perhaps,  by  bony  spurs  on  the  ribs  or 
in  the  scapula,  the  work  of  pleuritis  deformans, 
or  due  to  exostosis,  a  fracture  or  to  syphilis. 

Howsomever,  a  similar  crepitus  in  the  scap- 
ula— mostly  discernible  only  in  auscultation— 
also  happens  in  very  lean  or  emaciated  persons, 
no  doubt  caused  by  friction  between  the  shoulder 
blades  and  the  ribs;  it  may  also  be  due  to  some 
muscular  action  and  is  most  frequently  heard 
in  pulmonary  tuberculosis.  The  patient  him- 
self is  not  always  aware  of  its  existence.  A 
differential  sign  between  the  two  forms  is  the 
fact  that  in  the  latter  case  it  proceeds  with  a 
symmetrical  rhythm  and  is  painless  except  in 
unilateral  atrophy  of  the  dorsal  muscles. 

And  yet  we  come  across  patients  who  com- 
plain of  the  annoyance  occasioned  by  this  noise, 
as  well  as  of  the  pain  that  accompanies  it.  Fur- 


120  GENERALIZED   PAIN 

ther  questioning  may  elicit  the  fact  that  the 
patient  experiences  the  same  sensation  also  in 
other  joints  of  the  body.  We  are  safe  in  at- 
tributing the  whole  trouble  to  hysterical  causes. 
Emaciation,  often  enough  superinduced  by  vol- 
untary action,  is  evidently  the  originating  factor 
of  the  existing  neurosis.  The  diagnosis  can  well 
be  based  upon  the  claim  that  the  crackling  sound 
prevails  in  diverse  places,  and  also  on  the  other 
hysterical  manifestations. 

Pains  in  the  scapular  region  may  also  be  the 
result  of  some  anatomical  defect  in  the  shoulder- 
blades,  e.g.,  in  caries  or  acute  osteomyelitis,  a 
fact  which  is  of  interest  to  the  surgeon. 

We  are  strongly  reminded  here  of  morbid 
conditions  that  may  occur  in  the  adjacent  thora- 
cic organs,  especially  of  the  pleura  in  a  primary 
affection  of  the  lungs.  Not  only  tuberculosis, 
or  any  form  of  acute  or  chronic  infection,  ab- 
scess or  tumor  of  the  lungs  may  cause  these 
pains  by  way  of  encroachment  on  the  pleura 
or  in  combination  with  pleural  affections,  but 
we  must  also  look  for  primary  inflammations 
or  neoplasms  of  the  pleura  itself  as  the  orig- 
inating factors.  In  interlobar  pleuritis  (eni- 
pyema),  for  instance,  we  are  conscious  of  severe 
pains  in  the  region  of  the  shoulder  blades,  prox- 
imal to  the  spina  scapulas.  In  suppurative,  in- 
flammatory processes  of  the  bronchial  glands 


SHOULDER  121 

these    pains    are    rather    of    an    interscapular 
nature. 

Matterstock  mentions  a  peculiar  kind  of 
shoulder  pain  which  deserves  mention.  When 
we  glide  the  hand  with  firm  pressure  along  the 
crista  scapulae,  the  patient  who  is  suffering  from 
lobar  pulmonary  tuberculosis  speaks  of  severe 
pain  in  the  affected  section. 

Not  counting  any  of  the  previously  enumer- 
ated ailments  and  leaving  out  of  consideration 
even  a  possible  subscapular  bursitis  as  sources 
of  pain,  we  are  not  falling  into  an  error  when 
we  accept  a  painful  affection  of  the  shoulder 
blades  as  a  manifestation  of  intercostal  neural- 
gia. The  characteristic  signs  are:  the  seat  of 
the  pain  corresponds  with  the  anterior  angle 
of  the  scapula,  and  the  presence  of  pressure 
points,  especially  in  the  vertebra. 

Bilateral  shoulder  pains  should  direct  us  to 
recognize  deuteropathic  intercostal  neuralgia  due 
to  a  primary  affection  of  the  vertebras  or  of  the 
vertebral  joints,  of  the  ribs  or  of  the  spinal 
contents. 

One-sided  pains  of  great  intensity  in  one 
shoulder  blade  only  may  also  be  the  initial  symp- 
tom of  an  extramedullary  tumor  of  the  spinal 
cord.  Another  possibility  is  a  morbid  process 
within  the  chest,  especially  of  the  posterior 
mediastinum  in  the  form  of  intercostal  neuralgia, 


122  GENERALIZED   PAIN 

or  an  aneurysm  of  the  aorta  or  a  broncho- 
sarcoma. 

There  is  a  special  form  of  pain  at  the  apex 
of  the  scapular  angle.  All  morbid  processes 
that  possibly  may  occur  in  the  thoracic  cavity 
or  its  wall  may  here  be  involved,  and  must  be 
taken  into  consideration  whenever  these  pains 
come  under  our  observation. 

I  strongly  emphasize  the  fact  that  these  pains 
may,  when  coupled  with  local  pressure  sensitive- 
ness, figure  in  a  number  of  subdiaphragmatic 
affections  either  as  the  most  distinctive  irradia- 
tion pains  or,  at  any  rate  for  a  time,  as  the 
only  and  exclusive  pains  of  the  fundamental 
disease.  This  is  the  case  in  cholelithiasis,  in 
cholecystitis,  in  ventricular  ulcer  or  carcinoma. 
I  shall  refer  to  this  again  later  on. 

Pains  between  the  shoulder  blades,  at  the  apex 
of  the  scapula,  are  of  varying  genesis  according 
to  their  localization  either  between  the  scapula 
and  spinal  column  or  along  the  spinal  column. 
In  the  latter  case  the  differential  diagnosis  must 
follow  the  same  course  as  outlined  in  the  chapter 
on  "Pains  in  the  Sacrum." 

Affections  of  the  spinal  column  (bones,  joints 
and  cartilages)  and  its  contents  (membranes  of 
the  spinal  cord,  nerve  roots  and  the  spinal  cord 
proper)  claim  our  attention.  Pains  in  the  spinal 
column  at  this  level  may  originate  from  an  at- 
tack of  functional  neurosis  (spinalgia,  spinal 


SHOULDEB  123 

irritation).  The  diagnosis  must  proceed  from 
the  fact  that  the  pain  radiates  from  the  sacral 
region  upwards  into  the  shoulder  blade,  that  the 
skin  is  here  exquisitely  hyperesthetic,  and  that 
the  other  typical  symptoms  are  present. 

Other  morbid  conditions  in  the  posterior  me- 
diastinum loom  up  as  possible  causes  of  these 
pains.  Arrosion  of  the  spinal  column,  aneurysm 
in  the  arc  of  the  descending  aorta,  carcinoma  of 
the  esophagus  involving  one  or  several  of  the 
vertebrae,  are  all  possibilities.  The  diagnosis 
can  only  meet  with  an  obstacle  when  the  patient 
has  no  other  complaint  to  make  beyond  these 
local  pains,  as  may  very  well  be  the  case  in 
carcinoma  of  the  esophagus  or  in  the  earlier 
stage  of  aneurysm  of  the  descending  pectoral 
aorta.  If  there  is  no  pulsation  or  bruit  laterally 
to  the  spinal  column,  we  are  certain  to  find  a 
retardation  in  the  crural,  as  compared  with  the 
radial  pulse,  also  a  very  conspicuous  smallness 
of  the  former  as  compared  with  the  latter,  and 
above  all  the  Roentgen  picture  will  assist  in 
clearing  away  doubts  that  may  exist  in  the 
diagnosis. 

There  are  certain  affections  of  the  posterior 
mediastinum  which  do  not  directly  involve  the 
vertebral  column,  and  yet  are  associated  with 
pains  in  that  part  of  the  shoulder  blade  which 
is  adjacent  to  the  spine.  If  we  find  here  inter- 
scapular  sensitiveness  to  pressure  and  percussion 


124  GENERALIZED   PAIN 

in  the  spinous  processes  of  the  first  to  fourth 
vertebra,  we  may  be  sure  of  an  affection  in  the 
mediastinum,  or  in  the  heart  and  the  larger 
vessels.  Hyperesthesia  between  the  fourth  and 
eighth  vertebra,  or  even  below  the  latter,  points 
to  affections  in  the  stomach,  lower  esophagus, 
liver,  ventricular  ulcer  or  gastric  carcinoma. 

Pains  between  the  shoulder  blades,  or  between 
the  scapula  and  the  vertebral  column,  give  uls. 
the  impression  that  there  is  some  primary  dis- 
ease of  the  spinal  column  or  its  contents  which 
exerts  a  pressure  on  the  neighboring  nerve  roots. 
There  is  quite  a  list  of  such  possible  ills,  viz., 
caries,  spondilitis,  new  growths,  divers  affections 
of  the  vertebrae,  meningitis,  meningeal  apoplexy, 
hypertrophic  cervical  pachymeningitis  (syphil- 
itic), tumors  of  the  spinal  cord  or  the  membranes 
thereof,  inflammatory  conditions  of  the  cord  with 
lateral  meningitis  and  hematomyelia,  not  to  for- 
get foreign  bodies  in  the  intervertebral  foramina 
and  the  massing  together  of  neoplasmatic  metas- 
tases  or  leucemic  pseudoleucemic  or  lympho- 
granulomatous  infiltrations. 

Intercostal  neuralgia  between  the  shoulder 
blades  is  another  font  of  pain.  It  may  be  occa- 
sioned by  local  conditions,  e.g.,  by  disease  of  the 
neighboring  ribs  (neoplasms,  syphilis,  etc.)  or 
by  some  malformation  in  the  spine  (scoliosis) 
or  a  bronchial  or  pulmonary  affection  (bronchial 
carcinoma)  or  of  the  mediastinum  (aortic  aneu- 


SHOULDER  125 

rysm,  lymphosarcoma,  etc.),  or  it  may  be  merely 
a  pain  caused  by  fatigue  or  exhaustion,  or  it 
may  be  the  forerunner  of  herpes  zoster  or  its 
companion. 

Pains  which  are  due  to  overtaxing  or  over- 
tiring  of  the  spinal  column  in  the  sense  of 
vertebral  insufficiency,  belong  to  this  class.  The 
patient  does  not  of  his  own  accord  generally 
complain  of  backache,  but  rather  of  weariness 
and  languidness.  But  upon  closer  scrutiny  we 
find  a  decided  tenderness  on  pressure  and  tap- 
ping in  the  spine,  exquisitely  so  between  the 
shoulder  blades  and  laterally  from  the  corre- 
sponding vertebra?,  also  in  the  lumbar  vertebra? 
when  tapped  or  pressed  through  the  abdominal 
wall.  We  also  find  complicating  gastric  dis- 
turbances. This  form  of  insufficiency  may  be 
observed  in  almost  any  morbid  condition  of  the 
spinal  column,  such  as  scoliosis,  osteomalacia, 
chronic  ankylosing  articular  inflammation  of  the 
spine,  after  injuries  (carrying  heavy  burdens), 
in  anomalies  of  the  spine,  especially  at  the  age 
when  the  normal  bearing  power  of  the  column 
is  on  the  wane  (fortieth  to  fiftieth  year  of  age), 
not  any  the  less  after  wasting  diseases  or  ab- 
normal physical  exercises  or  overexertions.  The 
costal  region  is,  of  course,  included  in  this  sec- 
tion. There  may  be  tuberculous  caries,  syphilitic 
periostitis,  arrosion  of  one  or  several  ribs  caused 
by  an  aneurysm  or  similar  materies  morbi. 


126  GENERALIZED   PAIN 

Next  in  order  are  the  morbid  affections  of  the 
muscular  plexus.  Foremost  among  them  is 
rheumatism  of  the  interscapular  muscles. 

Rheumatic  myalgia,  myositis  in  syphilis  (pre- 
dominantly nocturnal  pains!),  polymyositis  ossi- 
ficans,  and  also  trichinosis  are  harbingers  of 
heavy  interscapular  pains.  We  find  them  in 
many  vocational  pursuits,  e.g.,  among  tailors, 
cobblers,  seamstresses  and  miners,  and  others 
who  have  to  lean  over  their  work  most  of  the 
time. 

Pains  in  the  back  count  among  the  primary 
signs  of  tetanus.  The  diagnosis  may  be  dis- 
turbed when  the  attack  comes  on  top  of  a  severe 
cold  thus  misleading  to  the  erroneous  classifica- 
tion of  "a  rheumatic  cold."  A  study  of  the 
other  tetanic  symptoms  should  correct  the  mis- 
take. 

In  chlorosis,  anemia,  asthenia  and  orthotic 
albuminuria  we  get  plenty  of  grumbling  about 
backaches  and  bodily  weariness.  The  fact  that 
rest  in  bed  brings  relief  is  a  strong  point  in 
favor  of  the  correct  diagnosis.  The  claim  made 
by  some  patients  that  leaning  the  shoulders 
against  the  back  of  a  high  chair  brings  relief,  I 
do  not  consider  of  much  value  in  this  connection. 

Back-shoulder  pains  due  to  some  myocardial 
weakness  must  be  included  in  this  paragraph. 
General  fatigue,  pains  in  the  loins  or  calves, 
ache  and  dullness  in  the  head,  dyspeptic  troubles, 


SHOULDER  127 

dyspnea,  cyanosis  even  after  minimal  physical 
exertion,  nycturia  or  oliguria  and  changes  in 
the  heart  itself,  are  all  good  pointers  for  the 
diagnosis. 

The  dragging,  cutting  pains  in  the  interscapu- 
lar  area  can  always  be  recognized  as  the  earliest 
symptoms  of  pulmonary  tuberculosis,  unless 
they  are  due  to  a  localized  dry  pleuritis  or  to 
hyperesthesia  of  the  skin.  Such  initial  symp- 
toms as  painful  palpation  of  the  museums 
cucullaris  (also  of  the  sterno-cleido-mastoid) 
and  sensitiveness  on  pressure  in  the  cervico- 
brachial  plexus  above  the  clavicle  should  give  a 
sound  foundation  to  the  diagnosis. 

In  various  diseases  of  the  mediastinum  the 
pains  lay  a  preferential  claim  to  the  region  be- 
tween the  left  scapula  and  the  spine.  If  they 
come  of  a  sudden  they  signal  an  inflammation 
of  the  cellular  tissue  of  the  posterior  mediasti- 
num or  its  glands.  Acute  mediastinitis  is  gen- 
erally of  a  phlegmonous  nature,  though  it  may 
be  also  in  the  form  of  a  localized  mediastinal 
abscess.  It  issues  from  some  morbid  process  of 
an  adjacent  organ,  inflammations  or  new  growths 
of  the  esophagus,  pericardium,  the  pleura  or 
lungs,  or  some  subdiaphragmatic  phlegmon 
which  has  extended  through  the  esophageal 
hiatus  into  the  posterior  mediastinum,  or  from 
a  primary  vertebral  or  costal  lesion,  tuberculous 
caries  being  the  most  common  among  these. 


128  GENERALIZED   PAIN 

PrevertebraL  actinomycosis  may  develop  from 
the  oral  cavity  through  the  cellular  tissue  of  the 
neck  or  also  from  the  esophagus.  The  diagnosis 
should  not  be  difficult  if  the  primary  port  of 
entry  of  the  actinomyces  is  found  in  the  oral 
cavity  (dental  actinomycosis)  or  in  the  neck 
or  in  the  respiratory  tract.  (Remember,  too, 
that  pulmonary  actinomycosis  may  also  be  the 
secondary  outcome  of  a  prevertebral  actinomy- 
cotic  phlegmon.)  Examination  of  pus  and 
sputum  and  the  Roentgen-ray  are  important 
adjuvants. 

Acute  inflammations  of  the  anterior  mediasti- 
num also  give  rise  to  pains  between  the  shoulder 
blades.  The  diagnosis  in  this  as  well  as  in  the 
former  instance  is  furthered  by  the  fact  that 
the  pains  are  interscapular  and  behind  the  ster- 
num, and  by  the  symptoms  of  mediastinal  irri- 
tation or  displacement  of  any  kind  (trachea, 
esophagus,  bloodvessels,  nerves,  glands).  Feb- 
rile conditions  are  of  a  septic  character.  A 
cutaneous  edema  in  the  jugulum  on  one  side  of 
the  sternum  or  above  the  clavicle  and  a  swelling 
in  these  sections  or  in  the  supraclavicular  fossa 
must  be  taken  as  warning  signals  of  a  possible 
perforation  of  the  mediastinal  abscess.  The 
X-ray  should  not  be  neglected  in  all  these 
cases. 

Dark  field  radiology  is  of  special  import  in 
chronic  fibrinous  mediastinitis  which  so  often 


SHOULDER  129 

follows  in  the  wake  of  indurated  pleuritis,  medi- 
astinal  lymphadenitis  and  inflammatory  affec- 
tions of  the  lungs  (phthisis,  diseases  of  the 
esophagus).  The  pains  are  retrosternal,  or  in- 
terscapular  with  possible  dysphagia  or  hoarse- 
ness. Additional  symptoms  are  a  descending 
laryngeal  pulse  (Oliver-Car darelli  symptom), 
aneurysm  and  dilatation  of  the  aorta,  medias- 
tinal  and  intrathoracic  glandular  tumors,  enter- 
optosis  and  unusually  accelerated  heart  action. 
However,  the  pains  between  the  shoulder  plates 
may  in  some  cases  be  the  only  perceptible  sign. 

Inflammatory  conditions  in  the  mediastinal 
cellular  tissue  as  well  as  in  the  retromediastinal 
glands  are  bound  to  give  rise  to  interscapular 
pains  localized  sometimes  only  on  one  side  of, 
but  mostly  within  the  spine  itself  and  generally 
on  the  level  of  the  2.  to  4.  dorsal  vertebra.  An- 
gina with  secondary  infectious  symptoms  and 
secondary  hemorrhagic  nephritis  are  often  the 
precursors  of  this  situation.  After  the  angina 
has  run  its  course  and  only  nephritic  residues 
are  left  behind,  we  will  often  enough  be  able  to 
observe  moderate  pains  between  the  shoulder 
blades,  not  infrequently  accompanied  by  diffi- 
culty in  swallowing,  but  always  by  a  perceptible 
rise  in  the  temperature,  to  disappear  gradually 
within  seven  or  eight  days.  I  incline  to  the  belief 
that  these  pains  are  attributable  to  a  receding 
retromediastinal  lymphadenitis  originating  in  the 


130  GENERALIZED   PAIN 

anginose  condition,  but  I  have  no  definite  proof 
for  it. 

More  often,  however,  these  pains  are  basic 
in  a  tuberculous  mediastinal  lymphadenitis,  pri- 
mary as  well  as  that  which  runs  parallel  with 
a  fully  developed  pulmonary  tuberculosis.  Of 
other  causes  it  is  meet  that  I  mention  here, 
muscular  affections,  hyperalgesia  of  the  skin, 
affections  of  the  bones  and  mediastinal  pleuritis 
(more  about  the  latter  later  on)  and  in  some 
rare  cases  an  acute  phlegmon  of  the  mediastinal 
cellular  tissue  proceding  from  a  tuberculous 
cavity  in  the  lung.  Chronic  indurated  medias- 
tenitis  and  plexus  pains  belong  here  also. 

We  can  safely  run  the  risk  of  looking  upon 
these  lymphadenitic  conditions  as  an  early  symp- 
tom of  phthisis.  They  are  disclosed  by  spas- 
modic coughs,  cyanosis,  dyspnea,  interscapular 
smothering,  the  Roentgen-ray,  sensitiveness  on 
pressure  either  on  the  side  of  the  2.  to  7.  dorsal 
vertebra  or  the  corresponding  spinous  processes, 
still  more  so  by  the  pressure  of  enlargements  in 
the  lymphatic  glands,  palpable  in  the  median 
axillary  line  of  the  thorax,  chiefly  in  the  4?.  inter- 
costal space.  But,  be  it  said,  the  last  named 
condition  does  not  in  many  cases  came  into 
evidence  until  the  tubercular  state  is  fully  de- 
veloped in  the  lungs.  If  pains  are  evinced  in 
the  aforementioned  location  during  esophageal 
probing  (Neisser)  we  have  definite  proof  of 


SHOULDER  131 

glandular  enlargements.  A  trial  injection  of 
tuberculin  followed  by  very  pronounced  shoulder 
pains  is  an  important  sign  for  the  diagnosis. 

Lymphogranuloma  of  the  mediastinal  glands 
and  anthracoid  conditions  of  the  peribronchial 
glands  claim  our  attention  also.  The  very  na- 
ture of  the  latter  affection  is  bound  to  cause 
pain  in  the  indicated  place,  and  so  do  also  any 
chronic  inflammatory  or  indurated  processes 
which  may  originate  from  it  in  the  periglandular 
mediastinal  cellular  tissue  (around  the  aorta, 
esophagus  or  trachea).  More  frequently  inter- 
scapular  pains  are  induced  by  neoplastic  diseases 
of  the  mediastinum  and  foremost  of  the  medias- 
tinal glands,  be  they  of  a  primary  (lymphoscar- 
coma)  or  metastatic  character.  As  a  rule  the 
pains  are  not  severe  or  at  any  rate  are  of  a 
negligible  quality  even  when  the  Roentgen  plate 
shows  already  deep  shadows.  Radiology  has 
the  same  diagnostic  value  also  in  bronchial  car- 
cinoma. Additional  diagnostic  signs  are:  hem- 
optysis in  persons  of  advanced  age  with  negative 
tubercular  conditions,  bronchial  stenosis,  fetid 
bronchitis,  abscess  or  gangrene  of  the  lungs, 
apyrexia  or  subfebrile  temperature  and  cachexia. 

Fresh  localized  pleuritis  and  pleural  adhesions 
also  give  rise  to  such  pains  which  are  either  of 
a  lasting  or  only  of  a  temporary  tenure  but  are 
often  exacerbated  by  local  pressure,  coughing 
or  deep  breathing,  etc.  Such  a  localized  pleuri- 


132  GENERALIZED   PAIN 

tis  is  apt  to  involve  the  posterior  mediastinal  or 
the  interlobar  visceral  pleura,  or  may  degenerate 
into  an  interlobar  tuberculosis  or  also  non-tuber- 
culous pleuritis. 

Patients  afflicted  with  bronchial  asthma  or 
asthmatic  bronchitis  feel  these  same  pains  be- 
tween the  shoulder  blades.  The  diagnosis  can 
here  always  fall  back  on  the  peculiarly  singing 
character  in  bronchitis,  the  increased  volume  of 
the  lungs,  the  typical  attacks,  examination  of  the 
blood  and  sputum  (Charcot's  crystals,  Cursch- 
mann's  spirals,  massive  eosinophile  cells,  bacte- 
rial deficiency). 

Little  attention  has  been  given  in  this  connec- 
tion to  chronic  tracheitis  and  chronic  asthmatic 
tracheobronchitis.  In  these  cases  the  interscapu- 
lar  pains  are  generally  superceded  by  the  par- 
allel painfulness  felt  behind  the  sternum.  I  have 
observed  this  in  patients  suffering  from  recurrent 
hay  fever  (conjunctivitis,  rhinitis,  bronchitis  and 
asthma)  when  there  were  no  traces  of  neurotic 
stigmata. 

In  acute  bronchitis,  especially  of  the  right 
large  bronchus,  a  dull,  burning,  stitching  pain 
between  the  scapula  and  spine  is  at  times  a 
matter  of  complaint,  possibly  due  to  consensual 
peribronchial  lymphadenitis. 

In  lobar  pneumonia  the  patient  is  likely  to 
complain  of  backache  even  before  the  clinical 
symptoms  are  definitely  developed.  This  is 


SHOULDEB  133 

particularly  so  when  the  inflammation  has  been 
restricted  for  some  time  to  the  hilum,  that  is  to 
say  before  the  parietal  pleura  has  been  affected. 
These  pains  would  in  such  an  event  come  from 
the  morbid  spot  in  the  mediastinal  pleura  as 
has  already  been  pointed  out  in  a  previous  pas- 
sage. This  fact  coupled  with  the  manifestations 
of  compression  and  enlargement  in  the  posterior 
mediastinum  should  enable  the  shrewd  observer 
to  recognize  the  true  nature  of  the  disease,  espe- 
cially if  he  calls  the  X-ray  into  service. 

More  frequently  the  causative  element  is 
found  in  diseases  of  the  esophagus.  If  it  is  a 
case  of  carcinoma  the  osseous  spine  need  not  be 
implicated,  but  the  immediate  surroundings  of 
the  esophagus  are  bound  to  be  affected.  The 
diagnosis  should  result  from  the  collateral  symp- 
toms. In  the  first  place  note  difficulty  in  deglu- 
tition, then  signs  of  congestion  or  enlargement 
of  the  esophagus,  the  verdict  of  the  probe  and 
the  evidence  of  the  X-ray  plate.  When  the 
pain  manifests  itself  only  during  the  act  of 
swallowing  or  is  rendered  more  acute  by  it  or 
by  the  introduction  of  the  stomach  sound  we 
have  additional  proof  of  the  existence  of  an 
esophageal  carcinoma. 

Among  the  other  painful  diseases  belonging 
here  I  will  mention  peptic  ulcer,  syphilitic  and 
tuberculous  tumors,  suppurative  conditions  of  the 
mucous  membrane  due  to  acetic  corrosion,  sten- 


134  GENERALIZED   PAIN 

osis  or  dilatation  of  the  esophagus  associated 
with  pressure  and  oppression.  The  patient  often 
complains  also  of  synchronous  pains  behind  the 
sternum,  but  at  the  lower  end  of  it,  in  peptic 
ulcer.  Still  I  have  seen  cases  in  which  no  com- 
panion pains  were  observed  and  the  interscapu- 
lar  pains  were  quite  independent  of  the  act  of 
swallowing  but  set  in  during  the  night  time, 
being  of  an  intensive,  tearing,  drawing  nature, 
especially  in  carcinoma  or  sarcoma  of  the 
esophagus. 

Rupture  of  an  aortic  aneurysm  into  the  gullet 
or  of  an  esophageal  carcinoma  into  the  trachea 
will  always  provoke  interscapular  pains,  al- 
though they  are,  as  a  rule,  located  by  the  patient 
in  the  breast. 

In  abdominal  diseases  the  pains  extend  fre- 
quently into  the  interscapular  district,  though  in 
bilious  colic  and  duodenal  ulcer  they  prefer  the 
right,  and  in  ventricular  ulcer,  rupture  or  per- 
foration of  the  stomach  and  splenic  affecting 
the  left  shoulder.  In  ventricular  pneumatosis 
they  also  radiate  into  the  retrosternal  region. 

In  subdiaphragmatic  diseases  pains  between 
the  shoulder  blades  are  the  most  prominent,  at 
times  even  the  only  symptom  that  presents  itself 
to  the  observing  mind.  Cholelithiasis,  for  in- 
stance, is  one  of  these  affections.  But  existing 
doubts  will  be  dispelled  if  we  find  that  the  cucul- 
laris  pressure  pain  is  unilateral  and  that  pressure 


SHOULDEB  135 

in  the  gallbladder  region  increases  the  interscap- 
ular  pain. 

Pains  between  the  shoulders  combined  with 
sacralgia  are  not  uncommon  in  patients  who 
suffer  from  abnormal  flatulence  or  defective 
flatus  due  to  chronic  intestinal  catarrh,  or  from 
obstinate  constipation,  or  also  from  abdominal 
plethora,  sclerosis  of  the  intestinal  arteries,  por- 
tal congestion,  phlebitis  or  phlebosclerosis  of  the 
visceral  veins,  (partly  due  to  nervous  conditions 
or  only  to  chronic  obstipation,  or  also  to  swal- 
lowing air).  Complaint  of  abnormal  gas  pro- 
duction, visible  distension  of  the  belly  and  if 
needs  be  the  Roentgen  pictures  are  the  founda- 
tions of  a  true  diagnostic  finding.  Appropriate 
therapeutic  measures  will  confirm  it. 

Diseases  of  the  gallbladder,  of  the  stomach 
(ventricular  ulcer  or  carcinoma),  in  rare  cases 
affections  of  the  spleen,  likewise  morbid  condi- 
tions of  the  pancreas,  in  fact,  of  the  entire 
peritoneal  cavity,  belong  in  this  category. 

The  interpretation  of  interscapular  pains  fol- 
lowing upon  diseases  of  the  aorta  is  rather  sur- 
rounded by  difficulties.  The  pains  prefer  the 
left  side,  although  at  times  they  invest  both  sides 
with  a  slight  punctuation  in  the  left.  Of  course, 
I  am  speaking  here  of  an  aneurysrn  situated  at 
the  spot  where  the  pectoral  aorta  arches  off  into 
the  descending  aorta.  The  cogent  points  are: 
visible  and  palpable  pulsation  in  the  left  painful 


136  GENERALIZED   PAIN 

zone,  systolic  murmur,  mediastinal  engorge- 
ment and  compression,  distinct  retardation  of 
the  crural  pulse  and  that  of  the  abdominal  aorta 
as  compared  with  the  pulse  rates  in  the  upper 
thoracic  sections,  especially  the  apex  impulse, 
and  the  radiological  finding. 

Another  peculiarity  is  that  the  pains  are  more 
acute  when  the  patient  lies  on  his  back,  but 
diminish  when  he  turns  around  to  rest  on  his 
abdomen.  And  again  they  are  sharpened  by 
physical  exertion  such  as  walking,  running  or 
exercising  the  arms,  whereby  the  aneurysmal 
sac  becomes  extended  and  calls  the  accompany- 
ing aortitis  into  action. 

Similar  conditions  prevail,  however,  in  any 
other  form  of  aortic  disease,  even  without  the 
formation  of  an  aneurysm,  e.g.,  in  syphilis  or 
sclerosis  of  the  pectoral  aorta.  There  is  still 
another  resemblance  between  the  pains  in  the 
shoulders  arising  from  aortic  sclerosis  and  those 
due  to  aneurysm  of  the  pectoral  aorta,  but  not 
in  a  pathognomic  sense.  It  is  this:  the  patient 
in  either  case  will  tell  you  that  the  pains  are 
materially  softened  when  he  presses  the  back 
against  some  solid  object,  e.g.,  the  back  of  a 
chair,  or  under  vigorous,  punching  massage  in 
the  left  interscapular  region. 

The  fixation  of  sclerosis  of  the  pectoral  aorta 
can  be  credibly  established  upon  these  symptoms 
even  when  arteriosclerotic  manifestations  in  the 


SHOULDER  137 

other  aortic  and  peripheral  vessels  are  wanting. 
A  distinctly  punctuated,  or  ringing  second  aorta 
tonus  above  the  descending  pectoral  aorta,  i.e., 
in  the  left  interscapular  space,  is  a  leading 
sign. 

A  certain  anatomical  affection,  chiefly  the 
outcome  of  a  true  angina  pectoris,  must  be  men- 
tioned here.  I  mean  sclerosis  (syphilitic)  of  the 
coronary  arteries,,  i.e.,  a  constriction  at  the  point 
of  exit  from  the  ascending  aorta.  In  other 
words :  when  a  patient  tells  us  that  he  is  molested 
by  rather  intensive  —  sometimes  only  dull  - 
pains  between  the  shoulder  blades  (perhaps  for 
months)  we  should  always  think  of  a  possible 
true  angina  pectoris.  The  question  to  decide 
here  is  whether  we  are  dealing  with  a  sclerosis 
of  the  ascending  pectoral  aorta  or  of  the  cor- 
onary arteries,  i.e.,  the  ascending  portion  of  the 
supravalvular  aorta.  We  shall  arrive  at  a  deci- 
sion when  we  find  definite  proof  of  myocardial 
changes  such  as  chronic  interstitial  myocarditis, 
or  myofibrosis,  or  degeneration  of  the  heart 
muscle,  or,  maybe,  an  aneurysm  of  the  heart 
together  with  typical  attacks  of  angina  pectoris, 
which  latter  may  come  on  just  as  well  when  the 
body  is  in  motion  or  completely  at  rest. 

If  these  conditions  are  still  further  aggravated 
by  acute  weakness  of  the  heart,  unusual  physical 
debility,  failing  pulse,  pallor  of  the  face,  cere- 
bral symptoms,  syncopal  incidents,  we  have  a 


138  GENERALIZED   PAIN 

strong  intimation  of  the  sudden  thrombotic  or 
embolic  occlusion  of  a  coronary  artery. 

A  rupture  of  the  pectoral  aorta  generally 
announces  its  arrival  by  a  sudden  most  violent 
pain  between  the  left  scapula  and  the  spine, 
though  ordinarily  it  is  preceded  by  a  series  of 
minor  pains.  The  rupture  may  find  its  way 
into  the  left  pleura,  or  into  the  left  lung  or 
into  the  pericardium.  There  may  be  present 
a  pre-existing  sclerosis  of  the  aorta,  an  ordinary 
or  a  dissecting  aneurysm  of  the  aorta.  At  times 
we  find  a  pronounced  hyperesthesia  of  the  skin 
in  the  affected  area,  but  always  the  typical  signs 
of  internal  hemorrhage.  The  outcome  is  fatal. 

We  should  ever  bear  in  mind  that  two  of  the 
aforementioned  diseases  may  simultaneously  in- 
habit the  same  body.  It  is  by  no  means  an 
unusual  occurrence  that  aortic  or  coronary  scler- 
osis travels  side  by  side  with  a  carcinoma  of 
the  stomach  or  of  the  esophagus,  or  a  gastric 
tumor  with  an  arteriosclerotic  basis. 

Pains  in  the  apex  of  the  shoulder — not  always 
localized  by  the  patient  with  exactness — ever 
point  to  the  possibility  of  a  spinal  or  intracere- 
bral  source.  A  cerebellar  tumor  or  any  morbid 
condition  that  encroaches  upon  the  occipital 
space  will  cause  such  pains.  The  proper  diag- 
nosis can,  of  course,  be  made  from  the  observa- 
tion of  other  typical  symptoms.  In  migraine 


SHOULDEB  139 

with  an  occiptal  base  the  pains  travel  via  the 
nape  of  the  neck  to  the  shoulders. 

'Tains  within  the  range  of  the  scapula,"  or 
rather  within  the  circumference  of  the  supra- 
clavicular  and  supraspinous  fossa  require  special 
attention  in  this  place.  I  do  not  refer  to  the 
pains  which  originate  in  any  of  the  organs  that 
lie  within  the  supraclavicular  fossa  itself — they 
are  dealt  with  in  the  chapter  on  "Pains  in  the 
Neck" — but  rather  to  those  which  radiate  from 
the  nuchal  muscles  and  from  the  cervico-brachial 
plexus  into  the  shoulders. 

The  proof  that  certain  pains  are  basic  in  the 
nuchal  musculature,  chiefly  in  the  cucullaris 
muscle,  is  furnished  by  the  fact  that  they  are 
felt  only,  or  at  any  rate  are  exacerbated,  when 
the  individual  muscle  comes  into  action.  Pres- 
sure, stroking  or  tapping  of  the  muscle  creates 
a  painful  sensation.  This  is  frequently  the  case 
after  unwonted  physical,  gymnastic  exercise,  in 
which  case  the  anamnesis  should  be  sufficient 
ground  for  a  proper  diagnosis.  Gout  and  rheu- 
matism and  certain  infectious  diseases,  e.g., 
plague,  are  other  causes  that  must  be  considered. 

It  is  somewhat  difficult  to  separate  the  initial 
stages  of  multiple  ossifying  myositis  from  those 
of  the  acute  suppurative  form.  In  both  we  find 
local  pain,  swelling  of  a  solid  consistence,  moder- 
ate rise  of  temperature,  and  subsequent  muscular 
induration.  When  bone  tissue  sets  up,  the  diag- 


140  GENERALIZED   PAIN 

nosis  will  be  clear.  All  the  other  forms  of 
myositis  show  no  specific  tendency  to  attack  the 
muscles  of  the  neck  or  back,  except  acute  derma- 
tomyositis  in  which  disease  the  pains  eventually 
radiate  from  the  brachial  muscles  into  the  nuchal 
and  dorsal  plexus. 

In  angina  pectoris  and  other  cardiac  affec- 
tions (paroxysmal  tachycardia  with  nodal  heart 
rhythm,  acute  dilatation  of  right  ventricle  with 
venous  engorgement),  right  -  sided  trapezius 
hyperalgesia  in  periappendicitis,  pains  in  the 
shoulder  muscles,  especially  in  the  cucullaris 
and  in  the  sternocleidomastoid  are  experienced. 
The  patient  rarely  complains  of  them,  but  we 
find  hyperalgesia  when  kneading  or  roughly 
stroking  the  affected  muscles. 

In  true  angina  pectoris  and  in  aortalgia  sub- 
sequent to  sclerosis  of  the  aorta  or  of  the  cor- 
onary arteries  the  patient  often  complains  about 
pains  in  the  left  shoulder.  They  are  localized 
either  in  the  supraclavicular  or  supraspinous 
fossa  and  are  felt  with  physical  movement  or 
exercise,  but  also  at  times  when  the  body  is  at 
rest.  Muscular  hyperesthesia  is  not  in  evidence. 
In  some  cases  the  patient  does  not  seem  to  notice 
the  pains  at  all,  but  when  asked  will  speak  of 
a  slight  pressure  in  the  chest  but  without  painful 
sensation.  This  is  an  important  danger  signal 
not  to  be  ignored  in  sclerosis  of  the  aorta  or 
the  coronary  arteries. 


SHOULDER  141 

That  the  cervicobrachial  plexus  is  the  causa- 
tive factor  of  predominant  pains  in  the  shoulder 
is  demonstrated  when  the  patient  complains  of 
a  sensation  of  weight,  rigidity  and  acute  pain- 
fulness  in  the  affected  part.  He  inclines  his 
head  backwards  and  away  from  the  tender  side 
(shaving  posture).  The  nerve  fibres  above  the 
clavicle  are  sore  to  the  touch,  the  pains  in  the 
periphery  of  the  involved  plexus  radiate  into 
the  arms,  paresthesias  and  motoric  weakness  are 
noticeable  in  many  cases. 

These  pains  are  often  due  to  new  growths 
which  are  forming  in  this  region,  especially  in 
the  supraclavicular  fossa,  but  may  also  branch 
out  from  some  morbid  process  in  an  organ  which 
has  only  a  subordinate  anatomical  relation  to 
the  supraclavicular  group,  or  none  at  all.  They 
may  be  in  part  the  manifestation  of  a  poly- 
neuritis  or  a  mononeuritis  with  a  local  cause 
perhaps  in  the  spine  or  in  the  spinal  canal  or 
in  some  morbid  process  that  has  already  reached 
ic  corresponding  supraclavicular  fossa.  There 

the  possibility  of  a  swelling  or  a  tumor 
leveloping  in  the  clavicle  (osteomyelitis,  caries, 
gummata),  a  disease  or  enlargement  of  the 
supraclavicular  lymphatic  glands,  the  formation 
of  an  aneurysm  of  the  subclavian  artery — all 
easy  to  recognize — or  the  elongation  of  the  costi- 
form  process.  In  the  latter  case  the  X-ray  will 
furnish  the  proof  where  palpation  fails. 


142  GENERALIZED   PAIN 

In  omarthritis  the  pains  are  not  felt  so  much, 
if  at  all,  in  the  joint  itself,  but  rather  in  the 
zone  of  the  cervico-brachial  plexus  above  as  well 
as  below  the  clavicle.  (See  also  chapter  on 
"Pains  in  the  Extremities.") 

These  plexal  pains  go,  however,  together  also 
with  other  quite  independent  diseases.  It  is  by 
no  means  uncommon  that  a  patient  who  is 
suffering  from  an  aneurysm  of  the  aortic  arc 
complains  solely  of  pains  in  the  right  shoulder 
if  not  in  both  shoulders,  whence  they  radiate 
first  into  the  right  and  later  on  into  both  arms. 
The  same  may  be  said  of  simple  sclerosis  or 
dilatation  of  the  aorta.  A  proper  consideration 
of  the  typical  symptoms  of  these  diseases  should 
reveal  a  correct  diagnosis. 

We  shall  find  pains  of  a  minor  degree  in  the 
chest  but  such  of  decided  acuteness  in  the  left 
supraclavicular  fossa  in  every  attack  of  angina 
pectoris  based  upon  sclerosis  of  the  aorta. 

Aneurysm  of  the  anonymous  artery  carries 
with  it  very  severe  pains  in  the  right  shoulder 
and  arm.  (See  "Cardiac  Pains.") 

Solid  tumors  of  the  mediastinum  produce 
shoulder  pains  as  an  initial  symptom.  The 
diagnosis  can  be  made  from  the  Roentgen  pic- 
ture, other  typical  symptoms  such  as  mediastinal 
sensitiveness  to  pressure,  localized  lack  of  reson- 
ance in  percussion,  tympanitic  dullness.  Bron- 
chial sarcoma  is  worthy  of  mention  here  also. 


SHOULDER  143 

The  sudden  appearance  of  a  pain  in  one  of 
the  shoulders  or  in  the  supraclavicular  fossa 
should  arouse  our  suspicion  of  a  lesion  in  the 
corresponding  axpex  of  the  lung  or  its  pl|eural 
coating.  Pneumonia  of  the  apex  accompanied 
by  pleuritis  of  the  apex  pleura  tends  to  an  acute 
perineuritis  of  the  cervico-brachial  plexus  and 
thus  gives  rise  to  considerable  pain  in  the  shoul- 
der. We  should  recognize  this  condition  from 
the  characteristic  symptoms  of  the  disease  de- 
scribed elsewhere.  If  the  pains  have  been  pres- 
ent for  some  time  we  should  look  for  some 
chronic  disease,  especially  tuberculosis  of  the 
pulmonary  apex.  The  pain  combined  with  ten- 
derness in  the  cervical  plexus  when  the  pressing 
finger  glides  slowly  in  a  forward  movement  over 
it,  will  give  proof  of  an  indurated  pleuritis  and 
subsequent  chronic  perineuritis  (eventually  neu- 
ritis) of  the  cervico-brachial  plexus. 

The  corresponding  primary  symptom  of  this 
apex  disease  manifests  itself  in  the  shape  of  a 
painful  sensation  in  the  cucullaris  muscle  when 
it  is  rolled  about  or  tapped  with  the  finger.  The 
patient  is  not  always  aware  of  its  presence  until 
the  sore  spot  is  touched  which  may  also  be  the 
seat  of  an  amyotrophic  condition. 

Interstitial  or  chronic  pneumonia,  apex  pleu- 
ritis either  fibrinous  or  exudative  (suppurative), 
also  superior  lobular  tumors  are  generators  of 
scapular  pains,  which  become  a  typical  diag- 


144  GENERALIZED   PAIN 

nostic  symptom  when  aggravated  by  moving  or 
raising  the  arm  up  high. 

Pains  in  the  fossa  supraspinata  emanate  also 
from  an  interlobar  empyema.  They  disappear 
when  the  pus  has  been  drained  off. 

Proliferating  growths  on  the  superior  pulmon- 
ary lobe  frequently  cause  similar  pains  when 
extending  upwards  they  encroach  upon  the 
plexus  that  lies  above  the  apex.  I  refer  to 
malignant  and  cystic  (echinococcic)  neoplasms. 
The  accompanying  pain  is  of  importance  for 
diagnostic  purposes. 

Shoulder  pains  awakened  by  tapping  or  ro- 
tating the  cucullaris  muscle  may  also  be  due  to 
some  inflammatory  process  in  the  diaphragmatic 
region  such  as  a  local  pleuritis,  or  also  a  perihe- 
patitis,  or  any  kind  of  inflammatory  subphrenic 
lesion,  or  perigastritis  or  perisplenitis.  In  these 
cases  a  rearward  pressure  of  the  fingers  will 
elicit  pain  within  the  borders  of  the  outer  and 
median  third  of  the  right  cucullaris  muscle. 

Analogous  conditions  may  prevail  in  acute 
appendicitis  even  when  the  liver  is  intact  and 
the  subdiaphragmatic,  subhepatic  and  pleural 
cavities  are  not  involved  (subhepatic  suppura- 
tions may  give  rise  to  pains  in  the  right  shoul- 
der). The  patient  complains  of  pain  in  the 
iliocecal  region  when  drawing  a  deep  breath. 
In  chronic  appendicitis  similar  pains  at  times 
make  their  appearance,  especially  in  the  right 


SHOULDER  145 

supraspinate  fossa  and  below  the  right  clavicle. 
The  long  continued  fever  and  the  emaciating 
effect  on  the  patient  are  apt  to  lead  to  an  erron- 
eous diagnosis  of  tuberculosis  of  the  right  apex. 

But  the  pains  may  be  also  localized  in  the 
left  side  when  the  primary  affection  is  in  the 
left  lobe  of  the  liver  (gumma,  carcinoma)  with 
subsequent  perihepatitis. 

I  include  here  diseases  of  the  pancreas  and  of 
the  neck. 


Backache 

The  term  "backache"  carries  a  double  mean- 
ing. In  the  language  of  the  patient  it  may 
mean  a  pain  which  is  felt  either  along  the  whole 
or  nearly  whole  of  the  vertebral  column,  or  only 
in  a  limited  zone  or  on  one  side  or  the  other  of 
the  spine,  that  is  to  say  in  the  region  that  lies 
between  the  loins  and  the  neck.  As  this  book 
deals  with  nuchal  and  scapular  pains  in  separate 
chapters,  the  reader  will  know  that  the  pains 
described  in  this  chapter  affect  the  district  which 
lies  above  the  lumbar  and  below  the  interscapular 
region. 

Some  patients  will  complain  of  pains  in  the 
back  which  by  other  patients  are  described  as 
pains  in  the  chest.  We  can  easily  guess  that 
that  really  refers  to  retrosternal  pains  which 
belong  to  the  chapter  on  "Pectoral  Pains." 

With  these  limitations  in  view  we  will  first  of 
all  consider  the  spine  as  the  seat  of  pain  claim- 
ing our  attention.  This  includes  all  the  acute 
and  chronic  diseases  of  the  osseous  part  of  the 
column  as  well  as  the  diffuse  affections  of  the 
spinal  contents,  viz.,  the  cord,  and  its  substance 
and  the  meninges. 

146 


BACK  147 

So  far  as  the  acute  affections  of  the  different 
vertebrae  themselves  are  concerned  full  details 
are  given  in  the  chapter  on  "Pains  in  the  Sac- 
rum." 

As  a  preliminary  remark  I  mention  here  that 
a  syphilitic  vertebral  periostitis  may  well  involve 
the  entire  spinal  column  even  in  an  acute  fashion 
thus  simulating  acute  articular  rheumatism.  So 
far  as  the  chronic  vertebral  affections  are  con- 
cerned I  wish  to  emphasize  the  fact  that  if  the 
whole  of  the  spinal  column  is  comprised  in  the 
articular  process  a  very  characteristic  picture 
is  framed:  the  physiologic  spinal  curvatures  are 
missing,  the  entire  column  has  the  appearance 
of  a  rigid,  straight  tube,  the  patient  bends  his 
knee-  and  hip- joints  in  order  to  maintain  an 
upright  posture,  and  the  head  is  pointedly  in- 
clined in  a  frontal  direction.  Such  a  diffuse, 
chronic  articular  inflammation  of  the  spine 
makes  us  think  of  a  possible  ankylosing  verte- 
bral inflammation,  of  rhizomelia,  or  arthritis 
deformans,  such  as  we  have  already  discussed  in 
the  chapter  on  "Pains  in  the  Sacrum,"  but,  be 
it  said,  identical  conditions  may  also  arise  from 
a  gonorrhoic  source.  The  fact  that  the  gonor- 
rhea happened  some  time,  perhaps  some  years 
ago,  that  the  patient  is  still  of  youthful  age, 
that  the  erstwhile  gonorrhoic  attack  was  asso- 
ciated with  gonorrhoic  arthritis  in  one  joint  or 
another,  e.g.,  in  the  knee,  should  always  prompt 


148  GENERALIZED   PAIN 

a  positive  diagnosis.  Perhaps,  the  day  is  not 
far  off  when  the  Roentgen-ray  will  be  an  ad- 
junct in  such  cases.  That  syphilis  is  another 
etiological  factor  has  already  been  mentioned  in 
the  chapter  on  "Pains  in  the  Sacrum." 

The  vertebrae  themselves  are  also  a  possible 
focus  of  pains.  Habitual  scoliosis  claims  here 
our  attention,  and  so  do  quite  a  number  of  mor- 
bid conditions  in  the  entire  osseous  skeletal 
frame.  For  details  see  the  chapter  on  "Pains 
in  the  Bones."  I  only  mention  here  passingly, 
pains  in  the  bony  spine  or  in  any  part  thereof 
may  be  occasioned  by  osteomalacia — especially 
senile — by  multiple  or  diffuse  neoplasia  of  the 
vertebrae  as  a  manifestation  ex  parte  of  diffuse 
osseous  neoplasia  of  primary  or  secondary  origin, 
also  by  Kahler's  multiple  myeloma,  but  rarely 
by  a  late  tracheitis  or  by  leucemia.  I  make  these 
remarks  here  because  primary  and  at  times  ex- 
clusive complaints  of  these  pains  are  ripe  in  these 
cases  and  may  even  be  accepted  as  early  symp- 
toms of  a  disease  confined  wholly  to  the  spinal 
region.  Remember  also  that  backache  combined 
with  pain  in  the  head  and  in  the  extremities— 
often  of  a  lancinating  character — are  not  infre- 
quent companions  of  acromegaly. 

Local  pains  in  the  bony  spine  may  be  recog- 
nized from  divers  objective  symptoms,  such  as 
deformities  in  the  sense  of  angular  or  arcual 
kyphosis,  local  painfulness  aroused  by  percus- 


BACK  149 

sion  or  digital  tapping,  radiating  pains  in  the 
waistline  or  in  the  extremities,  pains  by  sudden 
pressure  on  or  impaired  motility  of  the  spine, 
the  secondary  reaction  of  the  disease  on  the 
spinal  cord  and  nerve  roots,  and,  last  but  not 
least,  from  the  X-ray  picture.  Upon  these 
foundations  we  can  readily  build  up  the  special 
diagnosis  of  appurtenant  diseases  such  as  tuber- 
culous spondylitis,  neoplasms  and  syphilis  of  the 
vertebrae. 

In  chronic  tuberculous  spondylitis  the  pains 
are  mostly  localized  between  the  dorsal  and 
lumbar  or  between  the  cervical  and  dorsal  ver- 
tebrae. But  they  may  be  felt  in  any  other  place 
of  the  spine  and  come  on  when  the  patient  has 
been  standing  on  his  feet  or  been  walking  for 
some  time.  In  the  initial  stages  of  the  disease 
we  may  find  very  acute  local  painfulness  when 
we  ask  the  patient  to  lie  down  in  an  arched 
position,  i.e.,  resting  the  body  on  the  back  of 
the  head  and  on  the  heels.  Often  enough  the 
patient  does  not  succeed  in  assuming  this  posture 
owing  to  the  exceeding  painfulness  caused  by  the 
attempt.  Furthermore  there  is  local  sensitive- 
ness on  percussion  and  pressure  especially  in  the 
spinous  processes  of  the  affected  vertebrae,  also 
when  touched  with  a  hot  sponge  or  the  electrode ; 
there  is  distinct  motoric  restriction,  exquisite 
accentuation  of  pain  by  sudden  brisk  pressure 
on  the  spine  from  above,  e.g.,  a  jolt  on  the 


150  GENERALIZED   PAIN 

shoulder  or  on  the  top  of  the  head,  and  angular 
kyphosis.  The  latter  does  not  so  clearly  mani- 
fest itself  in  some,  particularly  in  the  lumbar 
vertebrae  and  generally  only  in  the  form  of  a 
diminished  physiologic  convexity.  The  X-ray 
findings  and  the  manifestation  of  compression 
of  the  spinal  cord  and  its  membranes  and  also 
the  intraspinal  nerve  roots  complete  the  direc- 
tions for  the  diagnosis. 

The  same  symptom  complex  applies  to  every 
other  form  of  spondilitis  or  caries  of  the  spine. 
There  is  a  chronic  form  of  spondylitis  which  re- 
acts painfully  to  the  aforementioned  downward 
jolt  on  the  shoulder,  is  accompanied  by  fever  and 
easily  mistaken  for  Pott's  disease.  It  is  due  to 
staphylococcus  infection,  is  of  a  gummatous, 
typhoid,  posttraumatic  or  metastatic  character, 
distinguished  by  central  necrosis  or  abscess  of 
the  bones,  but  rarely  of  a  gonorrhoico-metastatic 
or  actinomycotic  nature.  Similarly  a  chronic 
form  of  caries  with  formation  of  angular  ky- 
phosis the  special  diagnosis  of  which  can  only 
be  made  from  the  combined  clinical  picture,  with 
the  aid  of  the  Roentgen-ray,  from  the  serological 
reactions  and,  so  far  as  the  actinomycotic  state 
is  concerned,  through  the  proof  of  the  latter's 
pressure  in  the  respiratory  tract.  Echinococcus 
and  an  aortic  aneurysm  may  also  attack  the 
spine  and  cause  atrophy  or  kyphosis  in  several 
vertebrae.  The  X-ray  is  here  "first  aid." 


BACK 

Spondilitis  may  set  in  as  an  acute  affection 
and  run  its  whole  course  as  such,  e.g.,  staphylo- 
coccic  osteomyelitis,  strepto-staphylo-mycosis,  or 
other  acute  infectious  spondylitic  conditions  of- 
ten coupled  with  chills  and  high  fever,  local 
stiffness,  local  symptoms  in  the  spinal  cord  and 
its  meninges  or  nerve  roots,  or  local  edema. 
The  diagnosis  will  be  guided  by  the  X-ray,  the 
evidence  of  previous  infection  (in  acute  verte- 
bral osteomyelitis,  for  instance,  antecedent  an- 
gina or  other  diseases  leading  to  suppurative 
metastases)  and  the  co-existence  of  an  acute 
suppurative  osteomyelitis  in  some  other  bones. 

But  let  us  remember  that  a  tuberculous  spon- 
dylitis  may  be,  as  is  often  the  case,  the  imme- 
diate successor  of  some  acute  infectious  disease. 
The  chronic  syphilitic  and  the  actinomycotic 
forms  have  the  same  pernicious  habit.  But  this 
is  also  the  case  in  other  morbid  processes,  e.g., 
in  aortic  aneurysm  which,  though  it  be  chronic 
in  its  nature,  will  yet  at  times  suddenly  and 
without  apparent  provocation  arouse  very  dis- 
tressing pains  in  the  vertebral  bodies.  The  same 
conditions  prevail  also  in  metastatic  vertebral 
carcinoma. 

It  may  do  no  harm  to  remind  the  reader  that 
tuberculous  spondylitis  is  capable  of  attacking 
the  spine  in  several  distinct  places  at  one  and 
the  same  time,  and  that  arthropathic  vertebral 
inflammations  may  be  formed,  e.g.,  in  tabes. 


152  GENERALIZED   PAIN 

In  so  far  as  neoplasms  of  the  spine  are  con- 
cerned the  internist  must  know  that  in  sarco- 
matous  conditions  of  this  organ  the  primary 
forms  prevail,  while  the  secondary  forms  are 
more  in  evidence  in  carcinomata  of  the  vertebrae. 
Myeloma  and  lymphogranuloma  are  also  possi- 
bilities, but  the  diagnosis  of  these  two  primary 
neoplasms  is  more  difficult  to  make  than  that 
of  the  secondary  malignant  neoplasms  (nearly 
always  carcinomatous)  for  the  simple  reason 
that  in  the  latter  case  the  primary  neoplasm  is 
capable  of  definite  proof  no  matter  whether  the 
secondary  vertebral  neoplasm  has  arisen  from 
a  carcinomatous  organism  adjacent  to  the  spine 
or  originates  from  a  metastatic  condition.  If 
the  former  is  the  case  it  may  be  rather  hard  in 
the  beginning  of  the  disease  to  determine  whether 
the  pains  are  really  due  to  a  co-affection  of  the 
spine  itself  or  only  to  a  compression  of  the 
peripheral  nerve  trunks.  I  think  a  satisfactory 
solution  is  to  be  found  in  radiological  examina- 
tion and  with  the  aid  of  a  correct  clinical  differ- 
entiation between  a  neuritis  of  the  nerve  roots 
and  that  of  the  nerve  trunks. 

The  local  manifestations  in  vertebral  neo- 
plasia  are  principally  the  following:  marked 
intensity  of  the  local  pains.  They  are  of  a 
boring  character  and  never  cease  even  when  the 
patient  is  at  rest  (it  is  otherwise  in  caries).  The 
irradiating  pains  are  often  accompanied  by 


BACK  153 

herpes  zoster  (this  does  not  seem  to  happen  in 
caries)  or  by  paraplegia  dolorosa  (an  important 
diagnostic  factor).  The  local  pains  in  the  dor- 
sal vertebrae  are  felt  in  neoplasms  on  the  side 
of  the  spine,  but  in  caries  more  laterally  in  the 
thorax.  In  caries  and  tuberculous  spondylitis 
pressure  on  and  tapping  of  the  spinous  processes 
or  a  brisk  jolt  from  above  stimulate  the  pain, 
while  in  neoplasia  deep  pressure  laterally  from 
the  spinous  processes  has  this  effect.  In  caries 
there  is  angular  kyphosis,  in  neoplasia  it  is — if 
any  at  all — of  an  arcuary  form,  that  is  to  say 
several  vertebrae  become  evenly  prominent. 

It  is  not  necessary  to  consider  here  other 
primary  tuberculous  affections  such  as  enlarge- 
ments or  scars  of  the  glands,  abscesses  in  de- 
pendent parts,  or  the  age  of  the  patient,  all  of 
which  are  factors  of  interest  in  caries. 

The  metastatic  vertebral  carcinomata  are  by 
far  the  most  common  forms  among  the  neo- 
plasms of  the  spine  and  are  from  the  diagnostic 
standpoint  of  interest  insofar  as  they,  like  the 
primary  new  growths,  escape  recognition,  espe- 
cially in  the  thyreoid  glands,  in  the  ovaries,  in  the 
kidneys  (hypernephroma)  and  the  suprarenal 
capsules,  in  the  prostate,  sometimes  also  in  the 
mamma  or  in  the  testicles.  Unless  we  find 
additional  affections  of  the  bones  (multiple 
primary  tumors,  e.g.,  myeloma,  or  multiple 
metastatases)  the  diagnosis  is  ever  restricted  to 


154  GENERALIZED   PAIN 

the  aforementioned  manifestations  and  to  the 
X-ray. 

In  these  cases  errors  are  bound  to  slip  in  in 
the  identification  of  neoplasms  of  the  spine  and 
arthritic  affections  of  the  vertebrae,  the  anky- 
lopoietic  spondylarthritis  or  deforming  arthritis. 
And  this  is  more  likely  to  happen  when  the 
patient  is  suffering  also  from  a  deforming  osteo- 
arthritis  of  some  standing  and  complains  of  aches 
in  the  back  and  spine.  We  shall  be  enlightened 
by  the  milder  intensity  of  the  pains,  by  the 
predominancy  of  the  rigidity  over  the  pains, 
and  above  all  by  the  X-ray  picture.  The  blood 
test  and  the  more  rapid  appearance  and  prog- 
ress of  the  vertebral  neoplasm  are  also  telling 
factors.  This  is  preeminently  so  when  an  ap- 
parent vertebral  tumor  arises  from  a  chloroma. 

Uric  arthritis  in  the  appropriate  vertebral 
joints  must  not  be  forgotten.  It  may  be 
preceded  by  gouty  changes  in  other  joints  (po- 
dagra, etc. ) ,  yet  this  disease,  may  under  circum- 
stances, be  the  first  manifestation  of  the  morbid 
condition.  Look  for  retarded  nucleic  metab- 
olism as  the  final  means  for  a  correct  diagnosis. 

Diseases  of  the  adjoining  ribs  and  of  the 
spinal  contents  are  further  causes  of  backache. 
Pains  which  occupy  the  whole  or  at  least  the 
largest  part  of  the  back  are  not  infrequently 
the  initial  symptom  of  acute  as  well  as  chronic 
diffuse  intrasjnnal  morbid  conditions,  not  only 


BACK  155 

of  the  meninges  but  also  of  the  very  substance 
of  the  spinal  cord,  for  instance,  in  acute  polio- 
myelitis or  multiple  sclerosis.  In  pellagra  the 
same  observation  can  be  made,  although  in  this 
ailment  the  pains  are  sometimes  only  felt  in  the 
scapular  region,  no  doubt  as  a  reflex  action  of 
the  toxin  on  the  central  nervous  system. 

Acute  spinal  meningitis  belongs  to  this  series. 
The  chronic,  above  all  the  postraumatic,  serous 
forms,  it  must  be  mentioned,  often  lack  entirely 
all  the  typical  meningitic  symptoms  and  travel 
under  the  mask  of  neurasthenia;  but  the  diag- 
nosis can  secure  evidence  from  the  complaint 
of  headache,  backache,  vertigo,  abnormal  excita- 
bility and  psychic  moodiness,  coupled  with  the 
proof  of  increased  pressure  in  the  spinal  fluid. 

Encroaching  diseases  of  the  brain  that  raise 
the  intraspinal  pressure  of  the  fluid,  especially 
when  situated  in  the  occipital  fossa,  produce 
pains  within  the  nape  of  the  neck  and  in  the 
back.  Acromegaly  has  the  same  failing. 

Myxedema  arouses  pain  in  the  sense  of  rachi- 
algia:  extreme  tired  feeling,  especially  in  the 
early  morning  hours,  heaviness  and  pain  in  the 
extremities,  menstrual  disturbances  (menor- 
rhagia,  amenorrhea),  chills,  subnormal  tempera- 
ture, hoarseness  and  obstinate  constipation  are 
the  predominant  signs. 

Any  kind  of  irritation  of  the  posterior  roots 
of  the  spinal  cord  is  bound  to  react  with  a  pain- 


156  GENERALIZED   PAIN 

ful  effect  on  the  back.  These  pains  are  of  an 
encircling  nature  such  as  is  described  in  the 
chapter  of  "Pains  in  the  Chest."  If  the  pains 
are  confined  to  the  level  of  a  certain  vertebra 
we  must  bear  in  mind  that  they  may  originate 
just  as  well  from  the  bony  part  as  from  the 
inter  vertebral  foramina,  the  spinal  canal  or  the 
spinal  cord  itself,  or  may  also  be  due  to  a  pri- 
mary affection  of  the  spinal  ganglion  (herpes 
zoster).  The  pains  may  set  in  in  an  acute 
fashion  (poliomyelitis,  myelitis,  multiple  sclero- 
sis, hematomyelia,  thrombosis  or  emboly),  or 
may  also  take  a  decidedly  chronic  course.  They 
are  felt  as  a  rule  on  both  sides,  but  with  excep- 
tions. We  must  be  guided  by  the  seat  and 
development  of  the  causative  factor. 

A  purely  functional  neurosis  provokes  pain 
in  any  isolated  place  or  in  several  places  or  also 
in  the  entire  spinal  column  (in  the  whole  of  the 
back).  Such  a  rachialgia  or  spinal  irritation  is 
simply  a  manifestation  in  part  of  an  hysterical 
or  neurasthenic  disease  of  the  whole  nervous 
system.  Insofar  as  the  spinal  irritation  is  con- 
cerned we  must  not  only  expect  a  feeling  of 
painful  fatigue,  but  also  an  affection  of  several 
vertebrae  and  a  strongly  marked,  often  exces- 
sive hyperesthesia  or  a  hyperalgesia  of  the  skin 
over  the  stricken  vertebral  zone.  The  softest 
touch  is  extremely  painful,  much  more  so  than 
a  prolonged,  increasing,  deep  pressure.  The 


BACK  157 

slightest  movement  of  a  cold  or  hot  sponge  or 
the  application  of  an  ever  so  weak  electric  cur- 
rent over  the  affected  part  produces  a  most 
violently  painful  sensation. 

The  rachialgic  pain  in  hysteria  is  characterized 
by  the  fact  that,  when  the  attention  of  the  pa- 
tient is  diverted,  it  abates  or  vanishes  altogether. 
Yet,  for  practical  purposes  this  symptom  is  not 
always  applicable,  for  the  reason  that  there  are 
many  other  anatomical  lesions  which  respond  in 
a  similar  fashion,  especially  when  associated  with 
neurotic  conditions. 

Owing  to  the  abnormal  vascular  irritability 
in  spinal  irritation  we  often  find  in  the  painful 
zone  a  marked  vasodilatatation  to  even  a  slight 
mechanical  stimulus  (vasomotoric  paresis!)  and 
vice  versa  also  generalized  vasomotoric  mani- 
festations in  the  sense  of  swooning  seizures,  in 
rachialgia  and  hysteria,  also  cerebral  convulsions. 
In  accordance  with  the  individual  neurotic  con- 
stitution of  the  patient  we  may  also  observe 
other  concomitant  vaso-sympathetic  manifesta- 
tions such  as  abnormal  pallor,  dizziness,  palpita- 
tion of  the  heart,  nausea,  vomiting,  polyuria,  etc. 
The  neurasthenic  and  hysteric  stigmata  of  the 
patient  are  further  adjuvants  of  a  correct  diag- 
nosis. 

Nevertheless,  it  is  sometimes  rather  difficult 
to  separate  such  a  purely  functional  disturbance 
from  an  initial  anatomical  lesion,  principally 


158  GENERALIZED   PAIN 

from  an  incipient  vertebral  caries,  because  rachi- 
algia,  or  else  spinal  irritation  may  under  circum- 
stances be  the  only  symptom  of  the  existing 
neurosis,  despite  the  fact  that  it  is  confined  to 
one  solitary  vertebra.  In  such  doubtful  cases, 
especially  when  a  deformity  is  not  yet  apparent 
in  the  spine,  much  help  will  come  to  us  from 
the  consideration  of  the  following  points:  in 
neurosis  the  superficial  touch  is  more  painful 
than  deep  pressure,  in  the  anatomical  lesion 
(spondylitis)  the  intensity  of  the  pain  is  in  pro- 
portion to  that  of  the  pressure;  in  spinal  irri- 
tation the  attack  affects  several  vertebrae  and 
pressure  and  tapping  are  felt  in  like  measure 
in  each  of  them,  in  spondylitis  and  new  growths 
only  one  vertebra  is  sensitive  (but  not  necessarily 
so).  In  spinal  irritation  and  in  rachialgia  there 
is  no  locomotoric  spinal  restriction,  on  the  con- 
trary movement  and  diverting  of  attention  ease 
the  pain,  although  this  may  be  the  case  also  in 
rachialgia  in  which  even  cutaneous  hyperalgesia 
is  at  times  missing.  This  naturally  complicates 
the  differential  diagnosis  again.  But  if  the 
patient  finds  momentary  relief  from  pain  when 
lying  flat  on  his  back  despite  spinal  motoric 
impairment,  we  can  safely  decide  in  favor  of 
rachialgia.  Nevertheless,  the  same  phenomenon 
is  apt  to  occur  in  tuberculous  spondylitis.  Other- 
wise only  protracted  observation  and  the  Roent- 
gen-ray will  furnish  the  necessary  evidence. 


BACK  159 

There  is  still  another  point  which  we  must 
bear  in  mind,  viz.,  that  it  is  by  no  means  im- 
possible for  tuberculous  spondylitis  developing 
from  hysteria;  likewise  that  the  presence  of  an 
abscess  in  a  dependent  part  indicates  vertebral 
caries,  although  in  the  latter  instance  even  a 
clever  diagnostician  may  be  misled  when  dealing 
with  a  case  of  hysterical  rachialgia  in  which  a 
reflex  muscular  contraction  simulates  an  abscess 
in  a  dependent  part. 

Kiimmel's  disease  is  sometimes  erroneously 
taken  for  a  traumatic  neurosis.  The  nosological 
status  of  this  traumatic  spondylopaihia  is  not 
yet  quite  clear  to  me.  Some  authors  refer  to 
it  as  a  rarefying  spondylitis,  others  as  a  frac- 
ture of  the  vertebra,  or  an  infarction  or  a  soften- 
ing of  the  intervertebral  cartilage.  Perhaps  the 
X-ray  will  eventually  clear  up  the  situation. 

Pains  in  the  back  and  also  in  the  sacrum 
which  interfere  with  occupational  pursuits  are 
frequently  the  initial  symptoms  of  dementia 
precox  in  youthful  persons.  Observation  by  an 
experienced  psychiatrist  is  here  called  for. 

Of  course,  backache  is  the  logical  sequel  of 
scapular  affections  which  in  their  turn  may  be 
merely  an  extension  of  any  acute  or  chronic 
inflammatory  process  in  the  ribs  or  spine.  I 
refer  to  acute  osteomyelitis,  typhoid  or  tuber- 
culous osteoperiostitis  and  to  primary  or  meta- 
static  neoplasmata  of  the  shoulder  blades.  Their 


160  GENERALIZED   PAIN 

symptoms  are  fully  described  under  the  head- 
ings of  diseases  of  the  ribs  and  spine  and  in  the 
chapter  "Pains  in  the  Bones." 

Diseases  of  the  dorsal  muscles  —  see  also 
"Pains  in  the  Shoulder" — are  either  of  rheu- 
matic or  infectious  toxic  (influenza,  Weil's  dis- 
ease) or  myositic  (nocturnal  backache  in  syphi- 
litic myositis)  or  metastatic  neoplastic  origin. 
That  backaches  are  caused  by  them  goes  without 
saying.  These  local  pains  are  also  due  to  fatigue 
in  chlorosis,  anemia,  asthenia  and  orthotic  albu- 
minuria,  or  to  overexertion  in  emphysema  (re- 
current, exasperating  coughing).  We  must  add 
trichinosis  and  tetanus  when  the  dorsal  muscles, 
especially  the  extensor  dorsi,  are  involved.  Epi- 
demic cerebro-spinal  meningitis  belongs  here  also. 

I  have  already  mentioned  under  "Pains  in  the 
Neck"  that  backache  and  nuchal  pains  may  be 
occasioned  by  septic  infections  or  toxic  injuries 
of  the  muscles. 

In  the  chapter  on  "Lumbalgia"  I  have  like- 
wise referred  to  the  painful  affection  of  the 
dorsal  muscles  caused  by  sclerosis  of  the  arteries 
of  the  lumbar  muscles.  When  resting,  the  pa- 
tient is  at  ease,  but  when  he  goes  into  action 
the  pains  in  the  lumbar  region  set  in  either  on 
one  or  both  sides,  coupled  with  stiffness  and 
weakness  in  the  muscular  tract.  These  pains 
radiate  in  a  frontal  direction  towards  the  twelfth 
rib  and  the  iliac  crest,  but  there  is  no  local 


BACK  161 

sensitiveness  on  percussion,  neither  is  there  mo- 
toric  inhibition  in  the  spine.  The  cause  for  this 
lies  in  sclerosis  of  the  arteries  of  the  lumbar 
muscles  or  that  of  the  abdominal  aorta,  or  an 
aneurysm  of  the  latter. 

There  is  a  form  of  spinal  intermittent  lame- 
ness, which  is  due  to  sclerosis  of  the  arteries  of 
the  spinal  cord.  We  can  distinguish  it  from 
the  commoner  peripheral  form  of  intermittent 
claudication  by  its  peripheral  arterial  pulse  and 
by  the  infrequency  of  pain  in  the  extremities. 
The  patient  will,  but  not  of  necessity,  complain 
of  pains  in  the  back,  which  are  felt  in  walking 
but  disappear  when  the  limbs  are  at  rest.  The 
legs  feel  weak  and  show  increased  tendon  reflex. 
The  patient  shows  the  Babinski  sign,  later  spas- 
tic paresis  and  bladder  and  rectal  troubles. 

In  order  not  to  repeat  myself,  I  refer  the 
reader  to  the  sections  on  "Pains  in  the  Sacrum, 
in  the  Extremities,  Shoulders  and  Muscles,"  in- 
sofar as  the  intercostal  nerves,  lymphatic  glands, 
synovial  sacs,  and  also  the  skin  of  the  back  are 
here  concerned.  I  will  only  mention  tubercu- 
lous diseases  of  the  bronchial  glands  as  factors 
causing  backache  and  interscapular  pains.  Lo- 
calized erythromelalgia,  although  a  rare  disease, 
is  another  link  in  this  chain. 

In  posterior  mediastinal  pUuritis  the  pain  is 
felt  along  the  whole  length  of  the  dorsal  spine, 
including  the  interscapular  region,  no  matter 


162  GENERALIZED    PAIN 

whether  it  is  of  a  suppurating,  serous  or  fibrin- 
ous  nature.  The  latter  may  be  recognized  by 
a  pleural  friction  noise,  the  other  two  by  tender- 
ness in  the  spinous  processes  of  the  upper  and 
median  dorsal  column  and  by  an  ascending 
streaky  dullness  in  the  left  transverse  processes. 
In  further  extension  of  the  disease  the  breathing 
is  diminished,  suppressed  or  stertorous,  some- 
times there  is  egophony;  we  also  find  symptoms 
of  mediastinal  compression,  e.g.,  of  the  trachea, 
dislocation  of  the  trachea  and  of  the  larynx  to 
the  right,  paralysis  of  the  recurrent  nerve,  diffi- 
culty in  swallowing,  convulsive  coughing,  dys- 
pnea, constriction  in  the  branchial  portion  of 
the  vena  cava  or  the  azygos  vein,  inspiratory 
constriction  of  the  intercostal  spaces  and  of  the 
thoracic  fossae,  chills  and  high  fever,  and  later 
on  expectoration  of  fetid  sputum  due  to  per- 
foration of  the  pleural  abscesses  in  the  larger 
air  passages.  The  Roentgenogram  shows  a  dis- 
tinct dark  line  along  the  spinal  column. 

Posterior  acute  purulent  mediastirutis  pro- 
duces lateral  pains  of  the  spinal  column.  The 
general  septic  aspect,  mediastinal  irritation,  con- 
sideration of  the  causal  element  and  the  X-ray 
are  the  essential  requisites  for  establishing  a 
proper  diagnosis.  In  pulmonary  tuberculosis 
this  disease  runs  a  rather  insidious  course.  We 
notice  pains  in  the  back  and  chest,  sub  febrile 
temperature,  anemia,  emaciation  and  profuse 


BACK  163 

sweating.  The  X-ray  can  be  applied  in  the 
fibrinous  form  only. 

Indurated  mediastinitis  seems  to  confine  itself 
to  dorsal  pains.  (See  chapter  on  "Shoulder 
Pains.") 

Backache  of  lesser  intensity,  but  coupled  with 
preponderating  retrosternal  pains,  may  be  ob- 
served occasionally  in  bronchial  asthma. 

Backaches  in  the  region  of  the  dorsal  spine, 
with  irradiations  in  the  armpit  and  nipple,  and 
in  the  arm  itself,  should  remind  us  of  a  morbid 
condition  in  the  thoracic  aorta  such  as  arterio- 
sclerosis, chronic  aortitis,  especially  syphilitic,  or 
an  aneurysm;  also  of  a  deep-seated,  painful 
affection  of  the  esophagus,  chiefly  of  a  carci- 
nomatous  character. 

A  rupture  of  the  thoracic  aorta  is  heralded 
by  a  most  violent  pain  in  the  back  in  the  zone 
of  the  dorsal  spine.  It  comes  on  very  suddenly 
and  early  death  ensues. 

If  the  pain  is  located  between  the  tenth  and 
twelfth  dorsal  vertebra,  it  is  definitely  due  to 
some  trouble  in  the  thoracic  descending  aorta, 
i.e.,  aneurysm. 

Pain  to  the  left  or  right  side  of  the  lower 
dorsal  column  is  a  frequent  manifestation  of  a 
recent  basal  pleuritis,  and  therefore  also  indi- 
rectly a  sign  of  various  diseases  of  the  lungs 
and  other  subdiaphragmatic  or  even  more  dis- 
tant organs  which  give  rise  to  such  a  pleuritis. 


164  GENERALIZED   PAIN 

But  there  is  a  form  of  dry  pleuritis  which  is 
strictly  localized  and  essentially  insidious  in  its 
nature  and  for  that  reason  very  hard  to  recog- 
nize. Only  a  post  mortem  will  reveal  the  origi- 
nating cause  which  may  be  a  small  abscess  in 
the  lung  or  a  bronchial  carcinoma. 

Both  basal  adhesive  and  diaphragmatic  pleu- 
ritis are  pregnant  with  pains  in  the  back.  (Cf. 
my  book  on  ''Abdominal  Pain,"  Rebman  Com- 
pany, New  York.) 

These  pains  are  also  a  common  sign,  indeed 
the  initial  sign  of  some  pulmonary  infarct  preced- 
ing by  hours  or  even  days  the  characteristic 
bloody  sputum  and  the  other  physical  local  mani- 
festations. Only  Mahler's  sign,  the  presence  of 
slight  and  brief  rises  in  the  temperature  after  a 
chill  and  the  finding  of  the  source  from  which  the 
infarction  arises  can  make  the  diagnosis  positive. 

Gastric  affections  make  their  presence  known 
by  pains  in  the  level  of  the  loicer  dorsal  vertebrae, 
specially  on  the  left  side  of  the  spine  even  before 
the  patient  begins  to  complain  of  the  usual  dys- 
peptic or  gastric  troubles. 

But  when  these  pains  reach  up  to  the  eighth 
vertebra  they  constitute  the  one  and  only  absolute 
— though  not  always  reliable — sign  of  an  exist- 
ing carcinoma  or  ulcer  in  the  posterior  gastric 
parietes.  They  are  by  no  means  dependent  on 
the  quality  or  quantity  of  the  food  consumed, 
but  rather  influenced  by  the  position  or  physical 


BACK  165 

movements  of  the  body.  There  is  no  tenderness 
to  touch  in  the  epigastric  region,  but  frequently 
we  find  hyperesthesia  of  the  skin  or  of  the  spin- 
ous  processes — sometimes  only  one  vertebra  is  in- 
volved—in the  affected  area.  The  pains  resemble 
at  times  in  kind  and  intensity  those  observed  in 
caries.  In  some  cases  of  ulcer  in  the  pit  of  the 
stomach  they  make  the  impression  of  intercostal 
neuralgia  emanating  from  behind  the  lower  ribs 
to  the  left  of  the  median  line.  A  genuine  case  of 
ulcus  or  carcinoma  ventriculi!  A  combination 
of  pains  in  the  back  and  in  the  epigastrium 
strengthens  the  diagnosis  which  can  be  made  posi- 
tive only  by  chemical  and  bacteriological  examin- 
ation of  the  gastric  contents,  of  the  feces  for 
occult  hemorrhage,  and  by  the  Roentgen-ray. 

There  is  still  a  different  kind  of  backache 
which  occurs  in  gastric  ulcer,  but  even  more  so 
in  carcinoma  of  the  stomach.  It  may  set  in  at 
the  very  beginning  of,  or  develop  gradually  dur- 
ing the  run  of  the  disease.  We  hear  the  patient 
complain  of  periodic  attacks  of  very  severe  pains, 
similar  to  tabetic  crises.  They  persist  for  hours 
especially  in  the  dorsal  position  and  are  apt  to 
radiate  into  one  or  more  of  the  lower  left  inter- 
costal spaces  or  to  spread  fanlike  over  the  lower 
abdominal  region.  Practically  speaking  we  are 
justified  in  accepting  these  pains  as  a  symptom 
of  a  progressive  carcinomatous  metastasis  in  the 
retroperitoneal  glands,  a  carcinomatous  prolifer- 


166  GENERALIZED   PAIN 

ation  in  the  paravertebral  tissues,  a  constriction 
of  the  local  intercostal  nerves,  or  a  direct  invasion 
of  the  pancreas  by  an  ulcus  or  carcinoma  ventri- 
culi  (ulcus  penetrans).  There  is  also  the  possi- 
bility of  an  indurated  growth  expanding  into  the 
retroperitoneal  region.  Similar  conditions  may 
be  occasioned  by  other  localized  primary  diseases 
of  the  duodenum  or  the  pancreas,  etc.  Vertebral 
affections,  however,  such  as  metastasis,  do  not 
occur.  This  fact  combined  with  a  careful  X-ray 
examination  should  lead  to  definite  conclusions. 
Periodic  or  constant  backache,  though  variable 
in  intensity,  in  the  region  of  the  last  dorsal  ver- 
tebra to  the  right  of  the  spinal  column  is  a 
definite  sign  of  liver  complaint,  principally  chole- 
lithiasis of  the  gallbladder  and  acute  as  well  as 
chronic  cholecystitis,  in  rare  cases  also  of  a  gall- 
stone that  has  been  lodged  in  the  ductus  chole- 
dochus  above  the  ampulla  of  Vater.  The  patient 
complains  of  pains  in  the  back  when  leaning  over 
or  wearing  a  tight  belt  (sword  belt) ,  when  stand- 
ing erect  for  a  while,  or  when  sitting  for  some- 
time in  which  latter  position  he  finds  relief  by 
pressing  the  body  hard  against  the  back  of  the 
chair.  We  find  tenderness  to  pressure  and  per- 
cussion in  the  affected  zone,  very  likely  also  in 
the  spinous  processes  of  the  8.-10.  dorsal  ver- 
tebra, hyperesthesia  and  hyperalgesia  of  the  skin, 
tenderness  in  the  region  of  the  hepatic  fissure, 
palpable  changes  in  the  liver  or  the  gallbladder, 


BACK  167 

demonstrable  urobiligenuria  (urobilinuria)  and 
itching  of  the  skin.  The  proper  contemplation 
of  this  symptom  complex  together  with  the 
anamnesis  ought  to  forestall  any  possible  error 
in  the  diagnosis. 

The  same  means  for  recognizing  the  disease 
are  applicable  in  other  forms  of  cholelithiasis 
(cholecystitis)  except  that  the  pains  follow  a 
track  which  is  the  reverse  of  that  indicated  above. 
The  patient  tells  you  that  the  pains  start  in  the 
nape  on  a  level  with  and  also  in  the  shoulder 
sometimes  on  the  right,  sometimes  on  both  sides ; 
thence  they  travel  down  the  back  along  the  dor- 
sal spine  as  far  as  the  apex  of  the  liver  where 
they  branch  off  into  the  gastric  region.  In  some 
cases  they  are  continuous,  in  others  they  come 
in  isolated  attacks,  and  may  also  be  accompanied 
by  the  feeling  of  weight  and  fullness  in  the 
stomach.  I  saw  a  case  in  which  these  attacks 
occurred  every  second  night.  In  another  patient, 
a  woman,  the  pains  arose  from  the  level  of  the 
liver,  ascended  on  both  sides  of  the  spine  into  the 
shoulders  and  deflected  thence  either  into  both 
breasts,  or  by  change  into  the  nape,  the  arms 
and  the  chin.  How  difficult  to  separate  from  a 
stenocardia! 

If  certain  conditions  such  as  described  in 
"Abdominal  Pain"  prevail,  the  pains  arise  in  the 
left  side  of  the  spine  at  the  hepatic  level.  In 
other  words :  the  irradiation  is  erratic  in  its  action. 


168  GENERALIZED   PAIN 

This  caste  of  pains  should  put  us  in  mind  of 
a  possible  duodenal  ulcer  in  the  male,  or  of  a 
duodenal  carcinoma  in  either  sex.  The  intake 
of  cold  food  or  drink  arouses  or  increases  them. 
All  the  other  diseases  which  exhibit  themselves 
at  the  gate  of  the  liver  belong  here,  e.g.  appen- 
dicitis when  the  appendix  is  deflected  in  this 
direction,  for  in  all  of  them  this  particular  por- 
tion of  the  retroperitoneal  space  is  involved. 

With  the  same  force  all  this  applies  to  every 
painful  Uver  complaint  as  well  as  to  the  whole 
category  of  retroperitoneal  growths  below  the 
diaphragm  (pancreas,  abdominal  and  celiac 
aorta,  retroperitoneal  glands,  every  form  of  sub- 
diaphragmatic  pleuritis,  in  which  we  must  also 
look  out  for  tenderness  in  the  spinous  processes. 
For  particulars  consult  "Abdominal  Pain,"  also 
for  mesenteric  diseases  and  volvulus  of  the  small 
intestine. 

When  sudden,  very  vicious  pains  in  the  back 
with  collapse  are  witnessed,  look  for  a  perfora- 
tion of  the  stomach  or  of  the  small  intestine,  even 
though  the  abdominal  symptoms  (pain  and 
vomiting)  should  be  missing  altogether  or  be  of 
an  uncertain  nature  (e.g.  vomiting  occurs  also 
in  diseases  of  the  pectoral  organs).  Howsome- 
ever,  true  guides  are  found  in  the  tension  of  the 
abdominal  muscles,  the  indrawn  abdomen,  the 
exclusively  thoracic  breathing  and  the  final  col- 
lapse. 


Pains  in  the  Neck 

This  chapter  is  devoted  to  the  pains  occurring 
in  the  restricted  portion  of  the  body  which  con- 
nects the  head  with  the  trunk.  This  includes 
the  region  of  the  inferior  maxilla  as  far  as  the 
jugular  and  supraclavicular  fossa. 

The  first  disease  that  engages  our  attention 
is  cervical  myalgia  localized  in  the  sternocleido- 
mastoid  and  also  in  the  deeper  cervical  muscles. 
When  sudden  pains  set  in  after  taking  cold  or 
an  unexpected  drenching,  we  more  than  likely 
are  dealing  with  rheumatic  myalgia  and  its  after- 
effects, i.e.  caput  obstipum  (wry-neck,  torticol- 
lis) easily  recognized  by  the  etiology  and  the 
local  tenderness  of  the  superficial  muscles,  espe- 
cially of  the  sternocleidomastoid.  However, 
pain  may  be  also  reflected  in  the  latter  by  a 
morbid  process  in  the  cervical  lymphatic  glands 
in  which  case  a  false  diagnosis  can  easily  deploy. 
This  may  be  obviated  by  ascertaining  whether 
the  local  tenderness  is  in  the  muscle  itself  or 
rather  lies  in  the  deeper  tissues  beyond  it.  More- 
over, we  should  bear  in  mind  that  stiffness  in 
the  neck  is  often  the  reflex  action  of  an  irritation 
in  the  sensible  roots  of  the  cervical  muscles  due 
to  some  morbid  process  in  the  vertebrae,  e.g. 

169 


170  GENERALIZED  PAIN 

neoplasm  or  spondylitis,  or  else  of  the  spinal 
contents. 

Polymyositis  and  dermatomyositis  deserve 
mention  here  as  originators  of  pain  in  the  nuchal, 
dorsal  and  cervical  muscles,  causing  also  serious 
trouble  in  deglutition.  In  trichinosis  the  pres- 
ence of  eosinophiles  in  the  blood  should  clear 
the  view.  In  muscular  gummata  we  find  an 
indolent,  typically  nocturnal  pain.  The  differ- 
ential diagnosis  from  carcinoma  depends  on  the 
outcome  of  the  iodide  test  and  on  serological 
reaction. 

Pains  in  the  cervical  and  nuchal  muscles  very 
often  follow  an  attack  of  influenza,  the  same  as 
they  appear  also  in  the  thighs  and  calves,  no 
doubt  due  to  myalgia  or  myositis.  Fever  with 
leucocytosis  and  pains  in  the  eye  muscles  are 
typical  companions. 

The  commonest  source  of  pains  in  the  neck 
we  find  in  diseases  of  the  lymphatic  glands  and 
vessels,  in  fact,  in  all  acute  affections  of  the  face, 
the  oral  and  faucial  cavities,  the  pyriform  sinus, 
the  upper  esophagus  and  the  cervical  spine,  no 
matter  whether  they  are  of  infectious,  traumatic, 
toxic  or  thermic  origin.  These  glandular  en- 
largements are  present  in  all  forms  of  cynanche, 
as  an  indication  of  scarlatina  but  a  contraindica- 
tion of  diphtheria.  The  plague  infects  the  skin 
of  the  face,  the  oral  and  pharyngeal  cavities,  the 
mucous  membrane  of  the  nose,  covers  the  in- 


NECK 

ferior  maxilla  and  the  whole  of  the  neck  with 
buboes  which  fuse  into  a  solid  edematous  mass 
very  painful  to  pressure  so  long  as  the  patient 
retains  consciousness.  We  find  the  same  glandu- 
lar swellings  as  accompanying  signs  in  all  forms 
of  periostitis  and  stomatitis  (mercurial)  with 
pains  in  the  neck  as  the  logical  result. 

In  acute  leucemia,  glandular  enlargements  in 
the  inferior  maxilla  and  in  the  neck  should  be 
looked  for  as  a  common  but  not  regular  initial 
symptom.  But  more  about  this  in  another  place. 

What  seems  to  me  of  moment  is  the  fact  that 
these  acute  glandular  swellings  play  in  some 
cases  a  quite  independent  role,  because  the  pri- 
mary port  of  entry  of  the  infection  has  either 
not  yet  been  discovered  or  only  comes  into  evi- 
dence after  the  enlargement  of  the  glands  is 
already  fully  developed.  If  the  former  is  the 
case,  we  should  be  on  the  lookout  for  acute 
swellings  of  the  whole  glandular  complex  which 
belongs  to  the  periphery  of  the  inferior  maxilla, 
the  neck,  behind  the  sternocleidomastoid  and  in 
front  of  the  cucullaris  muscle,  all  the  way  from 
the  occiput  to  the  clavicle.  This  totality  of 
symptoms  combined  with  high  temperature  and 
a  general  feeling  of  illness  is  recognized  by  some 
authors  as  a  disease  per  se  and  is  yclept  "glandu- 
lar fever/'  I  do  not  share  this  opinion,  but 
incline  rather  to  the  belief  that  we  are  dealing 
with  an  infection  that  emanates  from  the  phar- 


172  GENERALIZED    PAIN 

yngeal  or  tonsillar  region  and  escapes  our  at- 
tention for  the  want  of  closer  inspection.  While 
these  conditions  prevail  principally  in  children, 
they  may  be  also  observed  in  adults. 

There  is  a  number  of  tonsillar  affections  which 
radiate  into  the  adjacent  lymphatic  system  of 
the  neck.  They  come  under  our  notice  only 
when  we  suddenly  discover  sensitive  dilatations 
in  the  cervical  glands,  while  the  primary  tonsilitis 
remains  in  hiding  until  we  question  the  patient 
about  difficulty  in  swallowing.  In  fact,  there 
are  cases  in  which  the  causative  factor  has  sim- 
ply passed  through  the  lymphatic  apparatus 
without  leaving  a  trace  of  infection  in  it.  If  we 
bear  this  well  in  mind  we  may  often  enough 
find  the  key  to  the  origin  of  many  a  septic 
affection,  even  of  an  etiologically  enigmatical 
endocarditis,  of  acute  nephritis  or  apparently 
acute  articular  rheumatism — without  reaction  to 
salicylic  drugs — with  or  without  purpura  or  ery- 
thema nodosum. 

Analogous  conditions  are  prevalent  in  acute 
appendicitis.  I  have  seen  cases  in  which  the 
typical  symptoms  of  appendicitis  were  accom- 
panied by  slightly  sensitive  enlargements  of  the 
cervical  glands  with  a  reddish  hue  in  the  tonsils, 
and  dysphagia.  In  such  instances  not  only  the 
lateral  cervical  glands  are  involved,  but  also 
those  which  are  situated  between  the  margin  of 
the  sternocleidomastoid  and  the  hvoid  bone. 


NECK  173 

On  the  other  hand,  it  is  also  possible  for  the 
primary  disease  to  become  demonstrable  only  two 
to  three  days  after  the  swelling  in  the  appur- 
tenant glands  has  already  manifested  itself.  We 
hear  the  patient  complain  of  pain  in  the  neck 
when  he  turns  his  head  to  one  side,  thus  inviting 
the  diagnosis  of  rheumatism  in  the  local  muscles. 
A  careful  scrutiny  leads  to  the  discovery  that 
the  seat  of  the  pain  is  really  in  the  muscular 
processes  and  a  true  diagnosis  of  tonsillitis  or 
lymphadenitis  is  the  result. 

Of  similar  importance  is  that  acute  glandular 
swellings,  no  matter  whether  they  be  spontane- 
ously painful  or  only  sensitive  on  pressure,  under 
the  inferior  maxilla  or  in  the  neck,  ever  remind 
us  of  the  possible  existence  of  erysipelas,  espe- 
cially in  the  rhinitic  zone.  I  have  seen  patients 
in  whom  such  an  apparently  independent  glan- 
dular swelling  existed  for  twenty-four  hours, 
with  fluctuating  temperature,  light  headache  and 
scarcely  noticeable  disturbance  in  the  general 
conditions.  But  on  the  following  day  the  outer 
surface  of  the  ala  nasi  betrayed  the  existence  of 
erysipelas.  Rhinoscopy  is  the  proper  adjuvant 
in  such  cases. 

If  we  are  confronted  by  chronic  enlargements 
of  the  lymphatic  glands  of  the  neck  and  the 
inferior  maxilla  we  must  make  the  same  careful 
examination  as  described  above.  If  this  leaves 
us  still  in  doubt,  we  must  inspect  the  oral 


174  GENERALIZED   PAIN 

cavities  and  the  scalp  (eczema,  pediculosis)  for 
the  causative  factor.  These  glandular  swellings 
are  sometimes  the  first  and  most  useful  symp- 
tom of  a  tumor  at  the  base  of  the  skull. 

On  the  other  hand,  they  may  form  a  part  of 
the  manifestations  of  a  multiple  or  universal 
glandular  infection,  such  as  occurs  in  syphilis, 
scrofulous  tuberculosis,  strumous  buboes,  leu- 
cemia,  aleucemia  and  in  lymphogranulomatous 
and  lymphosarcomatous  conditions.  Strictly 
speaking,  these  affections  do  not  belong  here, 
for  as  a  rule  they  are  not  of  a  painful  nature. 
But  I  will  add  to  the  foregoing  that  the  en- 
largement of  the  cervical  and  inferior  maxillary 
glands  may  be  a  pathological  condition  per  se, 
and  thus  present  a  primary  and  independent 
disease.  If  that  is  the  case  the  diagnosis  will 
waver  between  lymphosarcoma  or  lymphogranu- 
loma  and  tuberculous  lymphoma.  In  any  case, 
the  patient  complains  of  an  unpleasant  feeling 
of  tension,  slight  pain  in  the  glands,  and — in 
tuberculous  lymphoma — of  tenderness  to  touch. 
However,  more  about  this  in  the  passage  deal- 
ing with  "Glandular  Swellings." 

Phlegmons  of  the  cervical  cellular  tissue  are 
by  their  very  nature  of  a  painful  character. 
They  are  by  far  the  commonest  results  of  in- 
fectious inflammatory  processes  in  the  cervical 
glands,  for  which  reason  a  painstaking  scrutiny 
must  be  made  of  the  oral,  pharyngeal  and  nasal 


NECK  175 

(accessory)  cavities,  of  the  ear,  the  upper  re- 
gion of  the  larynx  and  esophagus  and  the 
thyreoid  glands.  The  diagnosis  should  be  obvi- 
ous, even  if,  owing  to  adenitis  or  periadenitis, 
we  find  a  diffuse  swelling  in  the  affected  cervical 
region,  together  with  reddening  or  a  livid  ap- 
pearance of  the  skin,  or  perhaps  fluctuation. 
Nevertheless,  the  manifestations  are  not  always 
so  plain.  In  fact,  the  most  severe  cases  of 
diffuse  extension  of  the  phlegmon  do  not  show 
them  at  all.  Here  the  existing  pain  must  guide 
the  diagnostician.  His  practised  eye  may  be 
able  to  detect  a  slight  swelling  and  a  scarcely 
perceptible  change  in  the  skin.  But  it  is  the 
manifest  general  symptoms,  such  as  local  fever 
with  almost  normal  body  temperature,  that  con- 
duct us  to  the  discernment  of  the  phlegmonous 
conditions  which  are  chiefly  due  to  streptococcic 
influences. 

Angina  Ludovid  is  a  subordinate  form  of 
cervical  phlegmon,  and  owing  to  its  proximity 
to  the  larynx  (edema  of  the  glottis)  is  of  a 
dangerous  character.  It  concerns  the  surgeon. 

There  is  another  form  of  cervical  phlegmon 
which  also  belongs  in  the  domain  of  surgery, 
but  nevertheless  is  of  interest  to  the  internist. 
I  mean  the  actinomycotic  phlegmon.  It  is  easily 
recognized  if  it  is  due  to  a  carious  tooth  or 
some  morbid  affection  of  the  jaws.  But  it  may 
also  originate  in  the  adjacent  cellular  tissue  of 


176  GENERALIZED   PAIN 

the  neck.  In  both  cases  it  is  characterized  by 
a  subacute  or  chronic  course,  trifling  painfulness 
and  sensitiveness  in  the  phlegmonous  infiltration, 
which  is  rigid  and  of  irregular  shape.  Bluish- 
red  abscesses  with  a  characteristic  serous  or 
sero-purulent  secretion  and  fistulous  perfora- 
tions are  formed.  In  acute  attacks,  which  are 
not  so  uncommon,  the  formation  of  granulating 
tumors  and  pus  proceeds  rapidly.  This  is  sig- 
nificant for  the  internist,  as  it  indicates  from 
which  direction  the  disease  is  descending  into 
the  mediastinum  or  ascending  into  the  cerebral 
region. 

Just  the  opposite  direction  is  taken  by  the 
diplococcus  infection  in  pneumonia,  i.e.,  the  pro- 
cess travels  from  the  thoracic  focus  upwards 
into  the  lymphatic  vessels  and  cellular  tissues 
of  the  neck  until  it  reaches  the  meninges.  In 
croupous  pneumonia  the  diplococcus  develops  a 
purulent  meningitis.  Few  patients  complain  of 
spontaneous  pain  in  the  neck,  although  some 
tenderness  in  the  intersternocleidomastoid  region 
is  always  observable. 

It  goes  without  saying  that  every  form  of 
acute  ascending  mediastinitis  is  ripe  with  pains 
in  the  neck.  The  inflammatory,  suppurative 
process  generally  deploys  from  the  left  supra- 
clavicular  fossa,  although  the  incissura  sterni 
jugularis  sometimes  forms  another  gate.  The 
diagnosis  is  plainly  staked  out  by  the  following 


NECK  177 

tokens:  the  pains  are  felt  behind  the  sternum, 
whence  they  radiate  into  the  back  between  the 
shoulder  blades  and  into  the  nape  of  the  neck; 
there  is  dysphagia,  fever  and  generalized  sepsis; 
we  find  a  primary  affection  in  the  adjacent 
bones  (ribs,  vertebra)  or  in  the  neighboring 
organs,  such  as  the  esophagus,  trachea,  lungs, 
pleura,  or  in  the  abdomen  (inflammatory  sub- 
diaphragmatic  growths),  or  an  edema  in  the 
skin  of  the  neck  or  above  the  sternum,  and  gas 
formation  in  subcutaneous  emphysema. 

An  acute  inflammation  of  the  submcurillary 
glands  is  likewise  a  frequent  cause  of  pains  in 
the  neck  which  may  reach  a  very  high  degree 
of  intensity  when  pus  forms  in  the  affected 
glands  occasioned  by  leucemia  or  leucemic 
stomatitis. 

There  is  hardly  any  appreciable  pain  in  epi- 
demic parotitis,  though  the  swollen  submaxillary 
glands  are  sensitive  to  touch.  When  the  en- 
largement of  the  parotid — as  is  usually  the  case 
— antedates  that  of  the  submaxillary  glands  the 
diagnosis  is  self-evident.  In  this  connection  it 
is  worth  while  to  remember  that  the  infection 
at  times  reaches  the  submaxillary  ahead  of  the 
auricular  salivary  glands,  or  may  not  even  im- 
plicate the  latter  at  all.  When  this  happens 
at  the  beginning  of  an  epidemic  before  typical 
cases  of  mumps  have  developed  the  diagnosis 
may  be  subject  to  errors,  especially  so  if  only 


178  GENERALIZED   PAIN 

one  of  the  thyreoids  is  as  yet  involved.  The 
presence  of  fever  or  a  general  indisposition  are 
not  much  of  help.  But  the  diagnosis  can  be 
made  positive  when  the  ovaries  or  testicles  evince 
tenderness  on  pressure.  A  blood  test  for  eosin- 
ophiles  is  also  advised. 

Inflammation  of  the  thyreoid  glands,  puru- 
lent as  well  as  non-purulent  (thyreoiditis  or 
strumitis),  is  heralded  by  pains  in  the  neck  and 
when  swallowing.  Casually  chills  and  fever 
are  initial  symptoms.  But  the  determinating 
signs  are  swelling  and  painfulness  in  the  thy- 
reoid, or  in  a  part  thereof,  the  fact  that  the 
pains  radiate  towards  the  head  and  the  as- 
cending swelling  causes  dysphagia.  The  in- 
flammation soon  establishes  itself  as  a  genuine 
disease,  supposedly  through  an  infection  of  the 
trachea  or  fauces — the  lymphatic  and  blood 
vessels  acting  as  carriers — or  it  may  be  (when 
afebrile)  the  drug  reaction  of  iodide.  It  may 
also  be  the  expression  of  a  generalized  infec- 
tion which  has  centered  in  the  thyreoids,  the 
causative  factors  being  the  bacillus  coli  or  other 
pus-producing  bacteria. 

On  the  other  hand,  an  inflamed  thyreoid  is 
often  merely  a  partial  symptom  of  some  fully 
developed  infectious  disease;  in  other  words,  a 
reflex  of  typhoid,  pneumonia,  erysipelas,  sepsis, 
pyemia,  influenza,  dysentery,  malaria,  cholera, 
tuberculosis  or  syphilis.  In  a  series  of  cases 


NECK  179 

the  inflammation  and  casual  suppuration  estab- 
lished themselves  in  some  section  of  the  hitherto 
normal  tissue  of  the  thyreoid  gland  in  the  nature 
of  an  acute  thyreoiditis.  But  when  under  this 
condition  the  gland  has  already  undergone  goi- 
trous changes,  the  pains  are  due  to  acute  stru- 
mitis.  In  rare  cases  a  local  hematoma  of  long 
standing  may  be  the  exciting  element,  and  lead 
to  a  false  diagnosis  of  carcinoma. 

To  the  internist  the  secondary  forms  of  thy- 
reoiditis and  strumitis  are  of  great  interest.  As 
they  are  mainly  after-effects  of  some  acute  dis- 
ease, for  instance  typhoid,  a  sharp  eye  must  be 
kept  on  the  thyreoid  glands  which  are  the 
favorite  place  for  the  colonization  of  the  typhoid 
bacillus. 

Owing  to  the  great  similarity  of  the  initial 
symptoms  in  both  diseases,  these  thyreoid  affec- 
tions are  often  mistaken  for  angina.  Only  a 
very  thorough  examination  of  the  patient  can 
prevent  such  an  error.  I  mention  here  also  that 
Baxedow's  disease  may  be  the  upshot  of  acute 
thyreoiditis  or  strumitis. 

Whenever  we  find  in  a  patient  an  enlarged, 
goiterlike  and  painful  thyreoid  gland,  we  must 
look  for  a  neoplasm,  mainly  a  carcinoma.  Rapid 
extension  and  hardening  of  the  growth,  emacia- 
tion and  the  anemic  look  of  the  patient  point  to 
sarcoma  in  younger  people,  but  to  carcinoma  in 
older  folks.  The  diagnosis  will  be  confirmed  by 


180  GENERALIZED   PAIN 

the  rapid  spread  of  the  tumor,  the  fixation  of 
the  thyreoid  gland,  when  it  cannot  be  moved 
about  by  the  examining  hand,  when  the  lateral 
cervical  nerve  and  vessels  appear  compressed, 
and  when  dyspnea  and  dysphagia  are  present. 
Nevertheless,  it  is  sometimes  difficult  to  dif- 
ferentiate between  strumitis  and  hemorrhage  in 
the  struma  or  neoplasm,  because  high  tempera- 
ture, leucocytosis,  pains,  swelling,  dyspnea  and 
dysphagia  are  all  common  symptoms.  Yet  it 
seems  to  me  that  in  strumitis  the  fever  is  higher 
and  the  secondary  character  of  the  disease  as 
well  as  the  local  and  general  inflammatory 
changes  are  demonstrable.  For  the  diagnosis 
of  hemorrhage  is  of  importance  that  the  tumor 
spreads  with  phenomenal  rapidity  for  several 
hours,  comes  to  a  standstill,  and  then  gradually 
recedes. 

The  Bloodvessels  and  Nerves  as  Irritating 
Factors 

Under  this  heading  I  mention  first  of  all  the 
arteries.  We  can  hardly  speak  here  of  real 
pain.  It  is  rather  an  aching  tension  or  pressure, 
an  uncomfortable  feeling  which  is  produced  by 
any  sclerotic  or  arteritic  change  in  the  coating 
of  the  arteries,  especially  when  the  cardiac  ac- 
tion is  accelerated.  Attacks  of  genuine,  some- 
times very  intensive  pain  along  the  line  of  the 
carotids  are  rather  attributable  to  some  primary 


NECK  181 

disease  such  as  angina  pectoris.  The  patient 
generally  complains  of  an  irradiation  of  retro- 
sternal  pains  along  the  left  side  of  the  neck  into 
the  nuchal  or  inferior  maxillary  or  dental  zone. 
These  pains  in  the  neck  and  teeth  are  at  times 
almost  unbearable.  A  demonstrable  arterio- 
sclerosis, periodic  anginose  attack,  hyperalgesia 
during  the  intervals,  and  tenderness  in  the  caro- 
tids on  palpation  should  furnish  sufficient  proof 
of  the  anginose  nature  of  this  painful  occurrence. 

Spontaneous  pains  due  to  an  affection  of  the 
veins  or  nerves  in  the  neck,  I  have  never  been 
able  to  observe.  But  sensitiveness  on  pressure 
in  the  vena  jugularis  interna  or  in  the  vagus 
is  not  uncommon,  and  I  consider  this  symptom 
of  high  diagnostic  value,  especially  in  phlebitis 
of  the  internal  jugular  vein.  Such  a  phlebitis 
may  be  the  sequel  of  an  otitis  media  or  else  of 
an  abscess  in  a  dependent  part  descending  from 
the  carotid  triangle. 

Moreover,  tenderness  in  the  lateral  upper 
region  of  the  neck  between  the  ramus  of  the 
inferior  maxillary  bone  and  the  mastoid  process 
is  a  serviceable  early  symptom  of  meningitis  or 
any  other  pressure  on  the  brain. 

In  a  similar  fashion,  a  thrombosis  of  the 
jugular  vein,  generally  as  a  continuation  of  a 
thrombosis  of  the  superior  vena  cava,  rarely  as 
a  primary  disease,  may  give  rise  to  a  slight  feel- 
ing of  pain,  or  rather  to  an  aching,  oppressive 


182  GENERALIZED   PAIN 

sensation  in  the  region  behind  the  sternocleido- 
mastoid  muscle.  The  diagnosis  can  be  made 
from  the  swollen  appearance  of  the  face  and  its 
bluish  tint,  or  from  a  local  edema  in  the  region 
of  the  parotis,  of  the  skull  or  of  the  right  arm 
as  well  as  on  the  neck  or  in  the  mucous  mem- 
brane of  the  oral  cavities  and  the  ectatic  condition 
of  the  cutaneous  veins. 

Furthermore,  tenderness  at  the  inner  margin 
of  the  sternocleidomastoid  must  direct  our  at- 
tention to  some  possible  disorder  of  the  vagus 
nerve.  When  young  people  complain  of  dys- 
pepsia and  gastric  troubles  and  in  consequence 
have  a  haggard  appearance,  and  I  find  tender- 
ness at  this  spot,  I  am  always  prepared  for 
the  beginning  of  a  tuberculous  affection  in  the 
apex  of  the  lung. 

With  gastric  carcinoma  the  patient  generally 
suffers  from  want  of  appetite  and  nausea  if 
food  is  placed  before  him;  but  there  are  cases 
in  which  the  very  opposite  happens,  i.e.,  intense, 
constant  craving  for  something  to  eat.  In  both 
these  cases  the  vagus  itself  need  not  be  at  all 
involved,  but  remain  absolutely  intact. 

But  not  only  affections  of  the  vagus  nerve, 
but  also  a  neuritis  or  neuralgia  of  the  phrenic 
nerve  (a  concomitant  in  diseases  of  the  heart, 
of  the  pericardium,  of  the  aorta,  of  the  dia- 
phragm or  of  the  subdiaphragmatic  organs), 
leads  to  extreme  local  tenderness  and  even  to 


NECK  183 

spontaneous  pains  in  the  side  of  the  neck,  either 
between  tne  posterior  border  of  the  sternocleido- 
mastoid  and  the  anterior  margin  of  the  scalinus 
anticus  muscle  or  between  the  two  processes  of 
the  first  named  muscle.  The  diagnosis  of  the 
phrenic  affection  is  notably  based  on  the  afore- 
mentioned painful  points  lateral  to  the  sternum 
and  spinal  column,  and  also  upon  the  abdominal 
pressure  point  (bouton  diaphragmatique)  at  the 
crossing  of  the  continued  sternal  line  and  the 
connective  line  of  the  two  10.  osseous  ribs. 

This  involvement  of  the  phrenic  nerves  the 
fibres  of  which  do  not  proceed  only  from  the 
4.,  but  also  in  part  from  the  3.  cervical  nerve, 
explains  the  presence  of  pains  in  the  neck  or  in 
the  cervico-nuchal  region  which  we  have  occasion 
to  observe  in  affections  of  the  diaphragmatic 
peritoneum  and  in  liver  complaints.  The  shoul- 
der pains  seem  to  be,  however,  the  preponder- 
ating element  in  these  conditions. 

In  chronic  lymphadenitis  of  the  neck  the 
pains  along  the  inner  border  of  the  sternocleido- 
mastoid  and  also  the  local  tenderness  are  of  a 
milder  form.  It  generally  originates  as  an 
upshot  of  chronic  tonsillitis  from  behind  the 
anterior  process  of  the  sternocleidomastoid  and 
in  the  retromandibular  region  (pain  in  the  ear) 
above  the  membranous  hypothyreoid  at  the  en- 
trance of  the  laryngeus  superior  nerve  and  at 
the  port  of  entry  of  the  facial  into  the  internal 


184  GENERALIZED    PAIN 

jugular  vein  and  the  paratracheal  glands.  This 
disease  is  frequently  mistaken  for  chronic  articu- 
lar rheumatism. 

When  pains  in  the  neck  are  combined  with 
trouble  in  swallowing,  we  are  led  in  the  direction 
of  an  irregularity  in  the  esophagus. 

An  acute  inflammation  of  the  esophageal  mu- 
cous membrane  (esophagitis)  due  to  some  me- 
chanical, thermic  or  chemical  injury  or  as  the 
Concomitant  of  an  acute  infection,  will  infest 
the  cervical  portion  of  the  esophagus  with  pain, 
which  radiates  at  times  downwards  behind  the 
sternum. 

Deglutition  increases  the  pain,  especially  in 
cases  of  acid  poisoning,  movements  of  the  cer- 
vical spine  have  the  same  effect,  food  gushes 
back,  there  is  a  copious  flow  of  phlegm  and 
sputum,  and  tenderness  at  the  side  of  the  throat. 
With  these  symptoms,  with  a  careful  examina- 
tion of  the  oral  cavities  and  the  aid  of  a  proper 
anamnesis  a  mistake  in  the  diagnosis  is  im- 
possible. 

In  chronic  esophagitis  these  symptoms  are 
generally  missing,  but  not  so  in  pharyngo-esoph- 
ageal  diverticulum.  But  even  in  the  latter  pain 
as  a  symptom  is  of  lesser  value,  if  we  except 
that  connected  with  deglutition  and  stenosis. 
Nevertheless,  there  are  cases  of  diverticulum  in 
which  the  patient  suffers  from  very  intensive 
pains,  no  doubt  caused  by  some  inflammatory 


NECK  185 

condition  in  the  wall  of  the  diverticulum  itself. 
The  diagnosis  should  offer  no  difficulties  as  all 
the  symptoms  are  of  a  strictly  characteristic 
form.  I  mention:  marked  stenotic  conditions, 
tumor  formation  with  a  peculiar  creaking  sound 
above  it  in  the  throat,  the  fetid  breath  and  flow 
of  saliva.  The  X-ray  should  do  the  rest. 

Globus  Hystericus 

It  consists  of  an  unpleasant,  at  times  very 
painful,  choking  sensation,  partly  due  to  hyper- 
esthesia  of  the  mucous  membrane  of  the  esoph- 
agus, and  partly  caused  by  a  spasmodic  con- 
traction of  the  pharyngeal  and  esophageal  mus- 
cles, commonly  called  "lump  in  the  throat." 
The  patient  has  the  feeling  of  a  lump  rising 
from  the  esophageal  orifice  of  the  stomach  to 
the  throat,  where  it  stops.  If  other  hysterical 
symptoms  are  present,  the  diagnosis  is  plain 
enough,  but  when  there  are  no  signs  of  hysteria 
we  meet  with  difficulties,  for  there  are  other 
diseases  which  produce  the  same  effect. 

We  all  know  what  terrible  spasms  grip  the 
throats  of  patients  affected  with  hydrophobia,  or 
tetanus,  so  there  is  no  need  for  me  to  dwell  on 
this  subject;  but  I  deem  if  necessary  to  say 
something  about  the  differentiation  between 
lyssa  and  lissophobia.  A  thorough  anamnesis 
and  the  incubation  period  (6  weeks  to  3  months) 
coupled  with  the  typical  symptoms  shoujd  leave 


186  GENERALIZED   PAIN 

no  doubts  in  our  mind  so  far  as  the  diagnosis 
of  lyssa  is  concerned.  If  the  patient  does  not 
show  spasmodic  conditions  in  the  throat  or  in 
the  respiratory  passages  when  we  blow  hard 
upon  the  skin — a  most  valuable,  in  fact  a  veri- 
table pathognomic  sign  for  rabies — if  there  is 
no  excess  of  the  reflex  action,  if  he  drinks  water 
freely  and  without  untoward  result,  we  may 
ease  his  mind  and  our  own  and  decide  in  favor 
of  lyssophobia,  especially  if  the  bite  of  a  dog 
or  other  mad  animal  is  denied.  By  the  way, 
lyssophobia  is  catching,  and  may  be  transferred 
from  one  person  to  another  by  mere  suggestion. 

It  is  different  in  tetanus.  Here  the  spas- 
modic contractions  are  the  first  sign  of  the  dis- 
ease, preceded,  perhaps,  by  lockjaw  (trismus). 

Spasmodic  contractions  in  the  throat  similar 
to  globus  hystericus  may  constitute  an  impor- 
tant accompanying  symptom  in  other  diseases; 
for  instance,  in  sclerosis  of  the  aorta  or  of  the 
coronary  arteries.  Anginoid  and  anginose  con- 
ditions also  manifest  themselves  in  this  form. 
But  they  are  of  minor  importance,  because  there 
we  have  the  evidence  of  the  originally  retro- 
sternal  localization  of  pressure  and  pain,  their 
irradiation,  the  fact  that  they  are  provoked  by 
bodily  movements  and  the  accompanying  un- 
easiness. Nevertheless,  there  is  a  suprasternal 
form  of  angina  pectoris  in  which  the  patient 
complains  exclusively  and  only  of  this  painful, 


NECK  187 

constricting  sensation.  Still  an  erroneous  diag- 
nosis of  globus  hystericus  may  slip  :n  if  the 
patient  is  a  female  who  claims  that  the  spasms 
in  the  throat  follow  some  psychic  emotion.  We 
should  then  endeavor  to  ascertain  whether  they 
do  not  also  follow  in  the  wake  of  some  physical 
exertion,  whether  they  do  not  also  come  in  the 
night  time,  whether  they  are  not  felt  in  the 
shape  of  an  oppressive  feeling  in  the  chest  or 
in  the  epigastrium.  If  these  questions  are  an- 
swered in  the  affirmative,  all  doubts  should 
dwindle  away. 

Insufficiency  and  debility  of  the  heart  (espe- 
cially Basedow's  disease)  give  rise  to  similar 
episodes.  They  crop  up  chiefly  after  an  un- 
usually heavy  meal,  especially  when  the  patient 
has  made  a  long  speech  or  smoked  to  excess. 
The  ordinary  symptoms  of  cardiac  insufficiency 
should  tell  us  the  truth. 

These  pains  are  particularly  disturbing  in  at- 
tacks of  essential  or  symptomatic  paroxysmal 
tachycardia.  The  diagnostic  conditions  are  dis- 
cussed on  another  page. 

If  in  a  mediastinal  disease  the  pectoral  vagus 
is  involved,  these  pains  are  turned  into  real 
deglutition  spasms,  reaching  sometimes  into  the 
deeper  registers  of  the  esophagus.  The  experi- 
enced observer  will  find  the  key  to  the  solution 
in  the  recognition  of  the  primary  affection,  and  in 
the  accompanying  manifestations  of  dysphagia, 


188  GENERALIZED    PAIN 

bradycardia,  arhythmia,  occasional  anginose  at- 
tacks, vagus  asthma,  pain  in  the  nervous  vagus 
of  the  neck,  and  intermittent  meteorism. 

Spasmodic  contractions  in  the  throat  caused 
by  flatulency  or  preceding  the  act  of  vomiting 
are  always  pure  and  simple  reactions  of  an 
irritated  nervus  vagus. 

In  asthmatic  attacks  and  in  hay  fever  these 
selfsame  spastic  pains  are  molesting  elements. 

But  they  are  also  at  times  partial  symptoms 
of  pharyngeal  crises  in  tabes,  and  may  be  ob- 
served in  botulism,  in  atropine  poisoning  and 
in  uremia. 


Pains  in  the  Nape  of  the  Neck 

In  order  tg  present  a  clear  survey  of  this 
subject,  I  am  taking  each  layer  of  tissue  that 
constitutes  the  nape  by  itself  as  a  possible  seat 
of  pain. 

I  begin  with  the  muscular  system,  for  the 
reason  that  local  pains  to  some  extent  originate 
in  the  nuchal  skin  through  furuncles  and  an- 
thrax, that  they  are  produced  by  the  movements 
of  the  head  in  scleroderma  on  account  of  the 
characteristic  stiffness  and  hardening  of  the  in- 
tegument which  is  also  the  case  in  myxedema. 
All  those  muscular  affections  which  are  men- 
tioned in  other  sections  of  this  bok  as  sources 
of  pain  in  the  sacrum,  in  the  shoulders,  in  the 
back  and  in  the  muscular  system  are  mutatis 
mutandis  discussed  here  also. 

When  the  nuchal  pains  are  only  partial  mani- 
festations of  other  synchronous  muscular  pains, 
the  diagnosis  cannot  be  imperilled.  But  they 
may  be  just  as  well  the  primary  signal  of  some 
generalized  muscular  disease.  Such  is,  for  in- 
stance, the  case  in  tetanus,  trichinosis;  and  be- 
cause in  Weil's  disease  the  muscles  of  the  nape 
are  so  often  primarily  attacked  with  the  most 

189 


190  GENERALIZED   PAIN 

intensive  pains  the  existence  of  an  epidemic 
"stiff-neck"  has  been  variously  mooted. 

In  Wolhynian  and  Pappataci  fever  severe 
nuchal  pains  have  been  observed.  Painful  ten- 
derness in  the  cucullaris  points  to  chronic  miti- 
gated sepsis.  Pains  in  the  nape  are  also  occa- 
sioned by  chronic  traumatic  myositis. 

Diseases  of  the  occipital  fossa  (tumor  in  the 
cerebellum)  or  of  the  meninges  may  affect  the 
sensible  posterior  nerve  roots  and  produce  stiff- 
ness in  the  nape  connected  with  pain  which  im- 
pairs the  motility  of  the  head. 

The  effect  may  also  result  from  ever  so  many 
morbid  conditions  in  the  spinal  column,  espe- 
cially in  the  region  of  intervertebral  foramina 
(arthritis,  rhizomyelia,  tumors,  infiltrations,  i.e., 
leucemic,  interspinal  canals,  aneurysms,  etc.), 
or  in  the  spinal  contents;  furthermore  in  all 
possible  expanding  extramedullary  diseases  (tu- 
mors, cervical  hypertrophic  or  luetic  or  tuber- 
culous pachymeningitis),  likewise  in  intermedul- 
lary  affections  (tabes,  syringomyelia,  multiple 
sclerosis,  myelitis,  tumors).  The  pains  are  often 
associated  with  local  stiffness. 

Of  course,  pain  and  stiffness  in  the  nape  are 
very  much  in  evidence  in  all  forms  of  meningitis 
and  pseudomeningitis.  The  differentiation  be- 
tween these  two  diseases  depends  upon  the  re- 
sults of  lumbar  puncture.  The  same  may  be 
said  of  abortive  forms  of  epidemic  meningitis. 


NAPE   OF   THE   NECK  191 

Although  the  presence  of  pain  in  the  nape,  in 
the  head,  the  extremities,  the  throat  coupled 
with  coughing  and  occasional  vomiting  arouse 
suspicions  which  gain  in  strength  by  the  addi- 
tion of  stiffness  in  the  nucha,  and  the  evidence 
of  Kernig's  sign,  yet  it  is  always  lumbar  punc- 
ture that  makes  the  diagnosis  positive,  especially 
when  also  meningococci  are  found  in  the  nasal 
and  pharyngeal  secretions. 

In  acute  poliomyelitis  intensive  pains  in  the 
nape  are  oftentimes  undesirable  guests,  whilst  in 
superior  myelitis  without  meningitic  complica- 
tions they  may  be  looked  upon  as  an  associated 
symptom. 

Of  the  various  spinal  diseases  in  which  these 
pains  constitute  a  predominant  sign,  I  will  men- 
tion Pott's  disease,  malum  Riwtii  and  tuber- 
culous inflammations  of  the  nuchal  vertebras. 
Distinguishing  symptoms  are:  when  the  patient 
is  lying  on-  his  side  and  wishes  to  raise  the  head 
he  is  likely  to  support  it  with  both  hands;  there 
is  local  deformity  in  the  spine;  we  find  local 
tenderness  upon  pressure  or  palpation,  painful 
reaction  to  the  touch  of  a  hot  sponge  or  an 
electrode,  or  to  downward  pressure  on  the  head. 
All  the  other  affections  which  are  discussed  in 
the  section  dealing  with  the  spinal  column  be- 
long to  this  category. 

It  may  be  of  interest  to  point  out  that  the 
first  four  vertebrae  are  the  privileged  quarters 


192  GENERALIZED   PAIN 

for  syphilitic  affections  of  the  spine.  The 
Roentgenogram,  the  anamnesis  and  serological 
tests  should  make  the  differentiation  from  tuber- 
culous or  rheumatic  conditions  clear. 

So  far  as  the  malum  Rustii  is  concerned,  I 
will  add  that  it  may  spring  not  only  from  a 
tuberculous  state  in  the  two  superior  cervical 
vertebrae,  but  also  from  a  neoplasm,  a  gumma 
or  a  fracture  in  that  locality,  not  to  forget 
arthritis,  rheumatism,  gout  or  syphilitic  gum- 
mata. 

Acute  articular  rheumatism  and  gonorrhoic 
affections  of  the  nuchal  vertebrae  are  members 
of  this  cotery. 

Cervico-occipital  neuralgia  is  the  next  item 
before  us.  It  is  typified  by  the  paroxysmal 
character  of  the  pains  which  radiate  from  the 
nape  into  the  occipital  region,  and  also  by 
tenderness  between  the  cervical  vertebra?  and 
the  mastoid  process.  Nevertheless,  we  should 
not  be  too  rash  in  making  a  positive  diagnosis 
from  these  symptoms,  because  similar  pains  may 
be  caused  by  some  preceding  primary  disease, 
e.g.,  by  a  tumor  or  by  an  ankylopoietic  spon- 
dylarthritis.  The  differentiation  will  be  found 
in  the  fact  that  the  movements  of  the  head  are 
free  from  pain  during  the  intervals  between  the 
attacks,  while  in  anatomical  lesions  of  the  pos- 
terior nerve  roots  there  is  continuous  motoric 
impairment  together  with  other  signs  pointing 


NAPE   OF  THE  NECK  193 

to  an  affection  located  at  the  place  of  origin 
of  the  nerves. 

The  lymphatic  glands  of  the  nuchal  region 
are  another  field  in  which  local  pains  may  arise 
from  some  morbid  condition,  e.g.,  from  lymph- 
adenitis. The  diagnosis  will  materialize  from 
the  finding  of  glandular  swellings  and  their 
origin  (primary  infection  in  the  head  or  tra- 
chea), or,  perhaps,  from  enlargements  of  the 
glands  in  general,  not  uncommon,  for  instance, 
in  cases  of  the  plague,  although  in  this  last- 
named  disease  the  pains  in  the  nape  and  also  in 
the  shoulders  are  more  likely  of  muscular  genesis. 

In  occipital  migraine,  pains  in  the  nape  and 
headaches  are  steady  companions. 

Primary  affections  of  the  posterior  oral  cavi- 
ties show  at  times  painful  reflexes  in  the  nape. 
In  some  cases  of  acute  angina  and  tonsilitis  the 
patient  complains  of  pains  in  the  corresponding 
nuchal  zone.  This  happens  particularly  when 
the  tonsils  are  affected  by  an  existing  chloroma. 
The  greenish  appearance  of  the  tonsils  and  the 
leucemic,  sub-  or  a-leucemic  condition  of  the 
blood  should  prevent  an  error  in  the  diagnosis. 
It  is  always  advisable  to  examine  the  oral  cavi- 
ties thoroughly  whenever  complaints  of  pain  in 
the  neck  are  made  by  a  patient. 

Any  disease  of  the  pleural  or  pulmonary 
apices,  especially  in  the  posterior  section  there- 
of, in  fact  all  acute  or  chronic  inflammatory 


194  GENERALIZED   PAIN 

processes  or  neoplasms  in  that  region,  are  con- 
nected with  pains  in  the  nape  of  the  neck,  and 
may  constitute  a  symptom  of  impending  phthisis. 
In  apical  pneumonia  these  paLis  are  of  great 
diagnostic  worth,  as  also  in  syphilitic  aortitis. 

In  diaphragmatic  pleuritis  pains  in  the  nape 
are,  no  doubt,  reflex  actions  emanating  from  the 
3rd-4th  cervical  segment. 

That  an  affection  of  the  sub  diaphragmatic 
peritoneum  or  of  the  serous  coating  of  the  liver 
often  causes  pain  in  the  nape,  in  the  neck,  and 
also  in  the  shoulders,  is  not  hard  to  undjrstand, 
because  the  fibres  of  the  phrenic  nerve  originate 
not  only  from  the  4th,  but  also  from  the  3rd 
cervical  nerves. 

In  the  majority  of  cases,  however,  the  pains 
caused  by  these  diseases,  i.e.,  subdiaphragmatic 
pleuritis  and  peritonitis  ( perihepatitis,  perisple- 
nitis),  are  not  spontaneous  in  their  nature,  but 
are  rather  evinced  in  a  certain  part  of  the  muscle 
when  we  gently  press  the  trapezius  between  our 
fingers  or  tap  the  supraspinate  fossa.  The 
middle  portion  of  the  trapezius  seems  to  be  most 
susceptible  to  this  reflex  action.  This  tenderness 
disappears  with  the  decline  of  the  serositis,  but 
returns  with  a  fresh  attack.  That  explains  also 
why  the  pain  in  the  nuchal  muscles  is  an  appre- 
ciable symptom  of  apical  pulmonary  tuberculo- 
sis, and  is  otherwise  a  useful  guide  in  the  diag- 
nosis of  subdiaphragmatic  morbid  conditions. 


Pain  in  the  Chest 

Pain  in  the  chest  may  be  caused  either  by 
morbid  conditions  of  the  thoracic  frame  or  by 
diseases  of  the  internal  organs  of  the  pectoral 
cavity,  if  not  by  complications  involving  both 
regions. 

Insofar  as  the  internal  organs  are  concerned, 
the  pains  due  to  diseases  of  the  heart  are  dis- 
cussed in  a  separate  chapter. 

The  pains  originating  in  the  wall  of  the  thorax 
are  the  result  of  affections  of  the  skin,  the  mus- 
cles, the  intercostal  nerves,  the  fascia,  the  sub- 
pleural  connective  tissue,  the  ribs  and  the 
mammae. 

Among  the  cutaneous  diseases  there  are  not 
many  that  are  of  direct  interest  to  the  internist, 
excepting,  of  course,  those  which  occur  in  the 
zones  of  Head,  and  these  will  be  discussed  in  the 
sections  dealing  with  the  corresponding  primary 
organic  troubles. 

But  medical  writers  report  cases  in  which  these 
zones  become  so  painful  that  the  patient  in- 
stinctively avoids  every  contact  with  the  affected 
portion  of  the  skin. 

Cholelithiasis  and  hyperesthesia  of  the  right 
upper  abdominal  and  lower  thoracic  integument 

195 


196  GENEKALIZED   PAIN 

will  cause  the  patient  to  keep  his  right  arm 
away  from  the  affected  part  for  fear  of  severe 
pains  elicited  by  contact  with  the  skin. 

If  these  pains  are  merely  symptomatic  of  an 
isolated  skin  disease,  they  belong  in  the  province 
of  the  dermatologist.  But  if  they  are  a  partial 
manifestation  of  a  general  disease,  e.g.,  of  adi- 
positas  dolorosa  (Dercum's  disease),  of  "sym- 
metrical" lipoma,  or  of  neurofibromatosis,  the 
internist  must  take  notice.  I  refer  to  this  sub- 
ject more  fully  in  the  chapter  on  "Pains  in  the 
Extremities."  And  again,  a  skin  disease  may 
be  the  superficial  sign  of  a  deep-seated  morbid 
condition.  In  this  sense  I  include  here  only 
those  cutaneous  and  subcutaneous  inflammatory 
changes  which  are  the  reflex  actions  of  in- 
ternal organs  of  the  thorax.  The  internist  will 
keep  here  a  sharp  lookout  for  subcutaneous 
abscesses  which  originate  from  an  empyema  ne- 
cessitatis,  or,  if  situated  in  the  precordial  region, 
are  connected  with  the  mediastinum,  but  not 
with  the  pleura,  or  also  may  be  a  derivation 
from  some  primary  disease  of  the  lungs.  Peri- 
pleuritic  abscesses  and  pulmonary  hernias  belong 
here,  too.  A  carcinoma  in  the  pleura  is  just  as 
likely  to  find  its  way  to  the  surface  of  the 
thoracic  integument,  thus  forming  an  unmis- 
takable symptom  of  the  primary  affection. 

Empyema  necessitatis,  cysts  with  or  without 
involvement  of  the  mediastinum,  perforation  of 


CHEST  197 

a  bronchiectatic  pocket,  peripheritic  abscess,  all 
are  subject  to  inflammatory  conditions.  This 
makes  it  so  easy  to  separate  them  from  abscesses 
due  to  perforation  of  a  tuberculous  sac  (cold 
abscess)  or  from  a  pulmonary  hernia  in  which 
there  is  febrile  reaction  of  the  skin. 

The  differentiation  between  the  first  three 
aforementioned  diseases  should  not  offer  any 
difficulties.  It  is  found  in  the  condition  of  the 
lungs  or  pleura  (empyema  or  bronchiectasis). 
Doubt  can  arise  only  when  an  abscess  is  formed 
by  some  anaerobic  bacteria  which  reach  the 
mediastinum.  Where  such  a  communication 
does  exist  the  diagnosis  should  not  be  difficult. 
Where  it  does  not  exist,  however,  we  run  the 
danger  of  being  misled  by  the  fluctuation  and 
crepitation  over  the  tumor  with  additional  gurg- 
ling rales  due  to  oscillations  of  intrathoraic  pres- 
sure. That  the  lung  itself  is  apparently  sound 
does  not  prove  anything  to  the  contrary.  But 
in  my  opinion  absence  of  the  tympanitic  percus- 
sion sound  which  one  might  expect  if  the  lungs 
were  involved,  and  also  absence  of  typical  res- 
piratory inflation  of  the  tumor  by  coughing  are 
definite  contraindications.  No  doubt  the  Roent- 
gen ray  will  on  some  not  so  very  distant  day 
come  to  our  assistance  in  this  matter. 

If  no  aerobic  abscess  is  in  evidence  the  differ- 
ential diagnosis  between  peripleuritis  and  a  per- 


198  GENERALIZED   PAIN 

forating  pleural  abscess  will  be  rather  puzzling. 
It  is  easy  enough  to  spot  a  perforation  of  the 
thoracic  wall  by  a  pulmonary  process  when  we 
have  definite  proof  of  a  primary  lung  disease 
and  unmistakable  pulmonary  symptoms  before 
us.  But  to  use  a  strict  localization  of  pains  and 
swellings  for  diagnosing  a  purulent  peripleuri- 
tis  I  do  not  consider  practicable,  because  we 
find  these  same  conditions  also  in  perforating 
empyema,  and  pain  is  always  associated  with  a 
non-perforating  pocket  empyema.  To  my  mind 
the  points  of  importance  are:  the  absence  of 
all  pulmonary  symptoms,  especially  coughing — 
early  severe  dyspnea  occurs  in  both  diseases;  it 
is  due  to  the  painful  breathing — and  there  is  no 
dislocation  of  the  mediastinal  organs  in  spite  of 
obstruction  and  dilatation.  In  empyema  neces- 
sitatis  I  have  never  been  able  to  see  more  than 
one  perforation  point.  The  X-ray  should  be 
very  helpful  in  the  diagnosis. 

Local  acute  inflammation  is  not  noticeable  in 
the  perforation  of  a  tuberculous  sac  into  the 
softer  parts  of  the  thorax,  neither  is  there  pain. 
The  skin  does  not  seem  to  react  to  pain,  although 
it  is  bulgy  and  livid  in  color,  crepitation,  tym- 
panitic  sounds  and  rales  are  perceptible  and  the 
tumor  has  a  squashy,  doughy  consistence.  The 
condition  may  easily  be  mistaken  for  pulmonary 
hernia.  Still  the  diagnosis  should  yield  positive 
results  from  the  observations  of  pocket  symp- 


CHEST  199 

toms,  the  presence  of  rales,  the  squashy  consis- 
tence of  the  tumor — in  pulmonary  hernia  the 
tumor  makes  a  creaky  sound  when  squeezed 
with  the  fingers — the  severe  involvement  of  the 
lungs  and  the  favorite  spot  for  the  perforation 
in  the  1.-3.  anterior  intercostal  space  in  pulmon- 
ary tuberculosis,  while  pulmonary  hernia  prefers 
the  upper  clavicular  region  or  6.  to  9.  anterior 
intercostal  space. 

This  applies  with  equal  force  to  those  cases 
of  pulmonary  hernia  which  are  not  of  traumatic 
orgin,  but  arrive  spontaneously  owing  to  ex- 
traordinary intrathoracic  pressure  on  an  other- 
wise abnormally  fragile  tissue. 

The  recognition  of  actinomycosis  arising  from 
the  air  passages  and  perforating  the  thoracic 
tissue  should  offer  no  dilemma,  because  this  dis- 
ease is  chiefly  a  chronic  progressive  infiltration 
making  its  way  to  the  surface  from  the  deeper 
tissues ;  it  is  the  formation  of  multiple  subpleural 
phlegmonous  foci  from  which  the  pus  works  up 
until  it  perforates  the  skin  in  the  shape  of  mani- 
fold fistulae. 

A  subcutaneous  hematoma  generally  sets  in 
with  sudden  severe  pains  in  the  chest  and  dys- 
pnea. When  spontaneous  in  origin  it  is  of 
particular  concern  to  the  internist.  As  a  rule 
the  affected  part  is  tinged  with  a  bluish  red 
color  by  which  it  can  readily  be  recognized. 

Aneurysms  of  the  pectoral  aorta  generally 


200  GENERALIZED   PAIN 

cause  only  moderate  pain  as  they  gradually 
expand  under  the  skin.  The  abnormal  bulging 
of  the  skin  and  very  strong  pulsation  together 
with  the  Roentgenogram  can  leave  no  room  for 
an  erroneous  diagnosis. 

Female  patients  often  have  occasion  to  com- 
plain about  pain  in  the  Mamma. 

Aside  from  mastitis  and  carcinoma,  the  only 
organic  disease  that  claims  the  attention  of  the 
internist  is  hypertrophy  which  causes  a  dragging 
pain  in  the  affected  mamma.  Similar  painful 
feelings  are  caused  by  any  infiltration  of  the 
mammary  glands  in  pregnancy  or  during  the 
lactation  period,  a  sort  of  muscular  fatigue. 
They  may  assume  a  permanent  form  in  leu- 
cemic  or  aleucemic  adiposity.  A  proper  support 
for  the  mammary  glands  relieves  the  pain  or 
removes  it. 

Mammary  carcinoma,  by  the  way,  at  times 
causes  periodic  attacks  of,  if  not  continuous 
lancinating  pains  which  radiate  into  the  arm, 
especially  when  the  seat  of  the  tumor  is  in  the 
exterior  upper  quadrant  of  the  mammary  gland. 
A  hard,  slightly  sensitive,  almost  immovable  and 
irregularly  formed  node  and  the  indrawn  nipple 
which  exudes  a  sticky,  serous  moisture  are  most 
reliable  symptoms  for  a  correct  diagnosis.  Such 
a  carcinoma  may  also  occur  in  the  adult  male, 
when  it  manifests  itself  in  the  lymphatics  in  the 
form  of  nodules  the  size  of  a  pinhead  or  pea 


CHEST  201 

which  produce  a  peculiarly  painful  sensation  in 
the  superficial  nerves  of  the  chest. 

Presenile  or  senile  involvement  of  the  mam- 
mary glands,  it  is  said,  also  is  connected  with 
local  pain.  Of  course,  there  are  other  appur- 
tinant  diseases  but  they  belong  in  the  domain  of 
surgery.  What,  however,  is  of  concern  to  the 
internist  is  pain  in  the  mammary  glands  occa- 
sioned by  neurosis,  neurasthenia  and  predomi- 
nently  by  hysteria.  In  these  conditions  the 
mamma,  sometimes  the  nipple  only,  constitutes 
a  very  strongly  marked  hyperesthetic  zone.  The 
slightest  friction  of  the  clothing,  even  of  the 
flimsiest  underwear  evokes  most  intensive  pains. 
The  presence  of  typical  stigmata  and  particu- 
larly that  of  psychic  symptoms  should  guarantee 
a  positive  diagnosis. 

In  hysteria  and  pointedly  so  in  neurasthenia 
the  mammary  pains  may  be  due  to  mastodymia, 
which  after  all  is  merely  the  expression  of  an 
intermammary  (at  times  even  very  stubborn) 
intercostal  neuralgia.  The  pains  are  of  a  shoot- 
ing, burning,  boring,  tearing  character  and  come 
in  periodic  attacks;  we  find  pronounced  hyper- 
esthesia  of  the  skin,  pressure  points  (external, 
axillary,  vertebral),  an  additional  anatomical 
lesion  of  the  glands  that  by  itself  is  a  possible 
originator  of  a  deuteropathic  mastodynia,  all  of 
which  combined  form  a  proper  basis  for  the 
diagnosis. 


202  GENERALIZED   PAIN 

There  are  cases  of  what  I  may  call  "imitation 
hysteria"  in  which  the  patient  complains  of  all 
the  typical  symptoms  of  such  a  mastodynia. 
The  condition  is  brought  about  by  self-delusion 
—auto-hypnotism — after  the  patient  has  visited 
a  friend  who  is  suffering  from  the  actual  disease 
and  now  imagines  she  has  it,  too. 

Pains  in  the  breasts  are  not  uncommon  during 
the  menstrual  period,  or  in  the  early  stages  of 
pregnancy,  also  during  the  climacterium,  with 
actual  swelling  of  the  mammary  glands.  These 
are  no  doubt  a  reflex  action  of  the  genital  glands 
on  the  mammary  glandular  system. 

Burning  pains  in  the  mamma  which  radiate 
into  the  adjacent  arm  have  also  been  observed 
in  cases  of  sclerosis  of  the  mammary  arteries. 
I  cannot  speak  here  from  personal  experience. 

So  far  as  intercostal  neuralgia  is  concerned, 
I  wish  to  point  out  that  it  is  always  risky  to 
judge  from  a  bilateral  condition  of  the  existence 
of  a  deuteropathic  affection  caused  by  a  lesion 
of  the  nerve  roots  either  in  the  spine  itself  or 
its  joints  or  in  the  contents  of  the  spinal  canal. 
Even  in  a  case  of  stubborn  unilateral  intercostal 
neuralgia  there  is  always  the  possibility  of  an 
existing  tumor  in  the  extramedullary  spinal  cord 
or  in  one  of  the  vertebrae.  Chronic  meningitis, 
a  serious  mechanical  injury  of  a  nerve  trunk 
caused  by  a  diseased  rib  (gummata)  or  by  an 
affection  of  the  pleura  (neoplasmata)  or  of  the 


CHEST  203 

mediastinal  organs,  e.g.,  anurysm  of  the  descend- 
ing thoracic  aorta  or  a  bronchus  carcinoma,  all 
are  included  in  this  list  of  eventualities.  Impor- 
tant for  the  diagnosis  is  the  fact  that  in  just  such 
cases  the  characteristic  pressure  points  are  fre- 
quently missing.  But  we  should  remember  that 
every  form  of  neuralgia  may  originate  from  a 
diseased  condition  of  the  central  nervous  system 
as  well  as  from  general  causes  such  as  diabetes, 
gout,  malaria,  chronic  constipation,  anemia  or 
chlorosis. 

In  cholelithiasis  pain  in  the  right  eleventh  rib 
often  resembles  an  attack  of  intercostal  neu- 
ralgia. 

In  some  cases  of  true  angina  pectoris  the 
typical  retrosternal  pains  are  accompanied  by 
pains  in  the  superior  intercostal  spaces.  When 
these  are  combined  with  deeper  intercostal  neu- 
ralgias we  may  well  take  them  as  the  signal  for 
an  aneurysm  of  the  pectoral  aorta. 

Pain  in  the  intercostal  nerves  is  a  constant 
companion  of  local  herpes  zoster  during  the 
entire  course  of  the  disease,  the  symptoms  of 
which  should  be  easily  recognized.  The  pain 
extends,  belt  like,  over  the  whole  affected  inter- 
costal space  and  the  eruption  consists  of  typically 
grouped  vesicles  and  subsequent  scars.  We 
must  not  forget  that  herpes  zoster,  especially  in 
its  bilateral  form,  is  often  a  partial  manifestation 
of  a  secondary  neuritis  of  the  nerve  roots,  or  of 


204  GENERALIZED   PAIN 

some  mediastinal  morbid  condition,  e.g.,  of  an 
aneurysm  of  the  aorta.  It  may  also  be  pro- 
voked by  arsenic  or  carbon  dioxid  poisoning. 

If  herpes  zoster  is  the  result  of  a  morbid 
process  in  the  intervertebral  ganglia  it  may  give 
rise  to  severe,  continuous  or  only  spasmodic 
pains  in  the  chest,  especially  in  the  posterior  or 
lateral  portion  parallel  with  the  seat  of  the  lesion. 
But  these  pains  are  likely  to  prevail  even  when 
the  attack  is  not  accompanied  by  herpes  zoster. 
This  refers  to  all  expanding  growths  in  the 
spinal  canal  or  in  the  vertebral  bones. 

Such  an  irritation  of  the  spinal  roots  is  no 
doubt  the  causating  factor  of  those  intense  inter- 
costal neuralgias  which  in  company  of  headache, 
neuralgic  pains  in  other  parts  of  the  body,  and 
articular  pains  constitute  the  initial  symptoms  of 
multiple  sclerosis. 

In  tabes  dorsalis  lightning  pains  in  the  inter- 
costal nerves  are  sometimes  experienced  with 
preference  in  the  lower  hypochondriac  intercostal 
spaces. 

The  tabetic  girdle  sense  is  associated  with  un- 
pleasant, slightly  painful  sensations  in  the  chest. 
When  this  symptom  is  the  first  and  perhaps  the 
only  complaint  made  by  the  patient  the  diagnosis 
may  not  be  so  easy,  especially  so  in  cases  where 
the  pain  is  confined  to  one  side  of  the  chest 
only. 

A  similar  girdle  sense  crops  up   not  infre- 


CHEST  205 

quently  also  in  neurasthenia.  But  when  this 
happens  it  is  advisable  to  make  a  thorough  search 
for  some  anatomical  affection  of  the  central 
nervous  system.  If  this  proves  fruitless  and  the 
typical  neurasthenic  symptoms  are  demonstrable 
the  diagnosis  may  be  made  positive. 

Furthermore,  girdle-like  paresthesias  involv- 
ing pain  are  likewise  possible  in  many  other 
spinal  diseases  such  as  meningitis  in  all  its  forms, 
syphilis  of  the  spine,  or  a  tumor,  syringomyelia, 
chronic  multiple  sclerosis,  etc.  Syphilitic  neuri- 
tis and  also  poliomyelitis  are  often  ripe  with 
pains  including  the  girdle  variety  in  the  back  as 
well  as  in  the  chest. 

If  in  poliomyelitis  girdle  pains  set  in  all  of 
a  sudden  and  with  great  intensity  we  should 
seriously  look  upon  this  condition  as  an  initial 
warning  of  acute  multiple  sclerosis,  or  hemato- 
myelia,  acute  myelitis,  embolism  or  thrombosis 
of  the  arteries  of  the  spinal  cord.  As  a  rule  we 
shall  find  a  concomitant  acute  paresis  if  not 
paralysis  of  the  two  lower  extremities,  or  some 
ailment  of  the  bladder  or  rectum.  In  that  case 
the  diagnosis  would  be  patent. 

This  is  also  true  of  diseases  of  the  spinal 
column  proper,  e.g.,  spondylarthritis  ankylo- 
poietica,  and  furthermore  of  diseases  of  the  bones 
which  cause  a  contraction  of  the  dorsal  vertebrae 
e.g.,  osteomalacia.  I  mention  also  arteriosclero- 
sis of  the  vessels  in  the  posterior  column  of  the 


206  GENERALIZED   PAIN 

spinal  cord.  The  diagnosis  in  this  case  must  be 
established  on  the  following  symptoms:  abnor- 
mal fatigue,  weakness  and  stiffness  in  the  lower 
extremities  when  walking  (in  the  absence  of  pain- 
ful intermittent  dysbasia),  pulsation  in  the  arte- 
ries of  the  foot,  the  Babinski  sign  during  or  after 
walking  but  absent  when  at  rest,  increase  of  the 
tendon  reflexes  in  demonstrable  arteriosclerosis 
of  the  peripheral  or  inner  vessels,  presence  of 
other  symptoms  pointing  to  arteriosclerosis  such 
as  angina  pectoris,  gastralgias  and  enteralgias, 
etc. 

These  girdle  pains  are  sometimes  a  very  im- 
portant manifestation  of  some  retromediastinal 
process.  An  aneurysm  for  instance  of  the  de- 
scending thoracic  aorta  at  the  point  where  the 
latter  passes  through  the  diaphragm  frequently 
betrays  its  presence  there  by  such  girdle  pains 
in  the  diaphragmatic  region.  They  are  felt 
during  physical  exertions,  or,  and  mostly  so, 
when  the  patient  lies  on  his  back  after  the  intake 
of  food. 

Some  patients  suffering  from  syphilitic  aorti- 
tis  complain  of  an  "uncanny  feeling"  or  girdle 
sensation  and  even  genuine  pain  in  the  region 
of  the  asternal  ribs.  The  cause  for  this  seems 
to  me  to  be  presence  of  an  arteritis  of  the  inter- 
costal arteries,  I  mean  a  constriction  at  the  point 
where  they  branch  off  from  the  pectoral  aorta. 
The  pains  may  be  felt  on  both  sides  or  on  the 


CHEST  207 

left  side  alone.  Analogous  observations  have 
been  made  in  typical  attacks  of  angina  pectoris 
and  also  in  cervical  tabes.  In  tabes  dorsalis 
some  patients  complain  of  a  feeling  as  if  the 
skin  over  the  cardiac  region  were  being  painfully 
pinched. 

The  girdle  pains  due  to  clonic  or  tome  spasms 
of  the  diaphragm  are  generally  confined  to  the 
region  of  union  between  the  diaphragm  and  the 
thoracic  wall.  The  chronic  form  of  these  spasms 
manifests  itself  by  singultus  which  may  endure 
for  several  days  under  very  severe  girdle  as  well 
as  epigastric  pains.  We  observe  this,  in  part 
at  any  rate,  in  abdominal  diseases  which  have 
a  reflex  action  on  the  phrenic  nerve,  e.g.,  in  the 
bladder  when  obnormally  distented  by  a  sur- 
charge of  urine,  in  prostatitis,  in  uterine  affec- 
tions ;  likewise  in  central  irritation  of  the  phrenic 
nerve  due  to  anatomical  lesions  of  the  brain  or 
spinal  cord  (encephalitis,  epidermic  singultus) 
or  caused  by  toxic  influences  (spastic  singultus 
in  uremia,  sepsis,  chronic  alcoholism),  in  neuroses 
(hysteria),  in  anemic  and  cachectic  conditions, 
in  anatomical  lesions  of  the  trunk  of  the  phrenic 
nerve  due  to  indurated  mediastino-pericarditis, 
possibly  also  following  an  aneurysm  of  the  pec- 
toral aorta  accompanied  as  a  rule,  by  indurated 
or  gummatous  mediastinitis.  We  find  this  same 
spastic  singultus  in  direct  irritations  of  the  serous 
coating  of  the  diaphragm,  for  instance  as  a 


208  GENERALIZED    PAIN 

manifestation  of  a  primary  or  more  or  less  dif- 
fuse peritonitis  in  the  lower  surface  of  the  dia- 
phragm, and  also  in  rare  cases  of  diaphragmatic 
pleuritis. 

It  is  more  difficult,  and  perhaps  only  with  the 
aid  of  the  Roentgen-ray,  to  recognize  the  tonic 
form  of  diaphragmatic  cramps.  It  occurs  as  an 
accompanying  sign  of  tetanus,  also  of  tetany, 
and  in  articular  and  muscular  rheumatism  due 
to  exposure  to  cold,  and  preeminently  so  in  hys- 
teria. The  patient  is  likely  to  be  attacked  by 
sudden,  very  intensive  girdle-pains  in  the  dia- 
phragmatic circumference;  dyspnea  and  cya- 
nosis are  very  pronounced,  the  abdomen  is 
distorted  and  the  pectoral  organs  are  pushed 
backwards.  Minor  attacks  of  this  nature  seem 
to  be  not  uncommon  in  hysteria. 

In  acute  diaphragmatitis  arising  from  pneu- 
monia, pleuritis,  peritonitis,  perihepatitis  or  peri- 
splenitis  we  are  often  called  upon  to  witness 
attacks  of  intermittent  or  also  long  continued 
pains  in  the  diaphragmatic  zone.  The  patient 
complains  of  girdle-like  pains  in  that  region, 
also  in  the  chest  and  back,  seriously  interfering 
with  deep  breathing.  This  condition  may  easily 
escape  observation  in  a  case  of  pneumonia  or 
cholecystitis;  the  more  so  when  we  are  dealing 
with  a  case  of  acute  diaphragmatic  pleuritis, 
especially  of  a  tuberculous  nature.  Under  these 
circumstances  cholecystitis  or  ulcus  ventriculi  are 


CHEST  209 

the  predominant  errors  in  the  diagnosis.  Proper 
search  for  pressure  points  in  the  phrenicus  and 
the  service  of  the  X-ray  are  the  only  correctives. 

Difformities  in  the  thorax,  chiefly  scoliosis  of 
the  spinal  column,  are  common  causes  of  pains 
in  the  chest.  A  chronic  affection  of  the  inter- 
costal nerves  is  possibly  the  originating  factor 
of  these  painful  sensations  which  may  be  uni- 
lateral only,  but  often  enough  are  felt  on  both 
sides. 

If  they  are  unilateral  in  the  left  inferior  inter- 
costal spaces  and  of  a  neuralgic  character,  they 
point  to  the  existence  of  an  ulcus  ventricuU.  It 
is  always  advisable  in  such  cases  to  look  most 
diligently  for  gastric  symptoms  such  as  periodic 
pressure  in  the  stomach,  pyrosis  and  indigestion 
lest  we  be  surprised  by  a  sudden  gastric  hemor- 
rhage. The  gastric  contents  should  be  carefully 
analyzed,  a  steady  watch  for  gastric  or  intestinal 
hemorrhages  must  be  kept,  also  for  hyperalgesia 
of  the  epigastric  skin,  for  Boas'  sign,  and  for 
deep  pressure  sensibility. 

The  larger  superficial  as  well  as  the  deeper 
lying  muscles  of  the  chest  may  be  the  habitat  of 
local  pains.  By  way  of  preliminary  mention  I 
wish  to  point  out  that  periodic  attacks  of  pain 
in  the  pectoralis  muscle  should  always  remind 
us  of  a  possible  angina  pectoris,  and  also  that 
subpectoral  suppuration  should  always  engage 
the  attention  of  the  internist  although  as  a  rule 


210  GENERALIZED    PAIN 

its  consideration  and  treatment  is  left  to  the 
surgeon. 

I  have  repeatedly  seen  in  my  clinic  cases  in 
which  the  patient  complained  of  intensive  pains 
in  the  chest  and  difficult  breathing  with  chills 
and  fever  which  were  taken  by  the  intern  as 
manifestations  of  an  acute  attack  in  the  respira- 
tory tract.  The  examination  gave  negative  re- 
sults so  far  as  the  pulmonary  conditions  were 
concerned,  but  there  were  indications  of  a  gen- 
eralized sepsis,  enlargements  in  the  anterior 
section  of  the  thorax,  especially  in  the  region 
of  one  major  pectoralis  muscle,  a  slight  edema 
of  the  skin,  very  intensive  local  tenderness,  and 
a  movement  of  the  arm  which  contracted  the 
pectoralis  major  elicited  most  intensive  pains  in 
that  muscle.  A  diagnosis  of  subpectoral  sup- 
puration was  made  and  confirmed  by  the  attend- 
ing surgeon  by  way  of  incision. 

The  diagnosis  may  be  even  a  more  difficult 
problem  when  an  empyema  and  a  subpectoral 
phlegmon  run  side  by  side. 

That  the  muscles  themselves  are  the  carriers 
of  the  localized  pain,  is  demonstrated  by  local 
tenderness  and  aggravated  painful  sensations 
which  accompany  an  attempt  to  activate  the 
appurtenant  muscles. 

After  all,  muscular  pains  in  the  chest  are 
generally  only  a  reflex  action  of  morbid  condi- 
tions in  other  muscles  of  the  body.  The  charac- 


CHEST  211 

teristic  symptoms  of  the  primary  disease  should 
facilitate  a  true  diagnosis.  But  due  regard  must 
be  had  of  the  fact  that  a  disease  which  involves 
so  large  a  district  as  the  muscular  complex  of 
the  chest  must  needs  carry  with  it  respiratory 
impairments  (suffocation)  and  diaphragmatic 
complications.  If  pulmonary  troubles  (pneu- 
monia) accede  or  the  examination  of  the  patient 
is  carelessly  made  the  diagnosis  is  apt  to  take  an 
erroneous  trend. 

In  acute  polyomyositis  or  trichinosis,  in  Weil's 
disease  and  also  in  gout  such  a  muscular  invol- 
ment  is  ever  a  contingency. 

Independent  muscular  pains  in  the  chest  are 
often  due  to  athletic  or  gymnastic  sports,  like- 
wise to  violent  and  protracted  fits  of  coughing 
(pertussis,  bronchitis,  pulmonary  emphysema). 
They  are  also  observed  in  occupational  pursuits 
— seamstresses,  cobblers,  tailors,  dentists — and 
are  due  to  the  constant  strain  on  the  muscles, 
bones  and  nerves  of  the  chest,  not  to  forget 
overfatigue. 

Exquisite  muscular  pains  in  the  chest  are 
seemingly  the  prerogative  of  pleurodynia  and 
rheumatism  of  the  pectoral  muscles.  If  the 
superficial  muscles  are  the  site,  the  diagnosis 
should  result  promptly,  for  we  find  in  both 
affections  muscular  tenderness  and  motoric 
pains,  in  protracted  cases  also  muscular  twitch- 
ing and  formation  of  nodes. 


212  GENERALIZED   PAIN 

In  more  severe  muscular  diseases  the  patient 
complains  not  only  of  pains  when  raising  the 
arm  but  also  of  such  which  accompany  coughing, 
sneezing,  swallowing  and  deep  breathing.  The 
latter  is  naturally  and  instinctively  avoided  and 
leads  to  congestion  of  the  bronchial  secretions 
with  complicating  catarrhal  conditions.  I  raise 
the  question:  Is  a  secondary  catarrh  the  sequel 
of  a  primary  rheumatism  of  the  pectoral  muscles 
or  is  it  a  primary  bronchitis  with  secondary  dry 
pleuritis? 

If  in  overfatigue  the  pains  persist  for  a  con- 
siderable period  of  time  we  should  remember 
that  pains  in  the  pectoralis  muscles  are  specifi- 
cally the  symptom  of  a  chronic  overtax  of  the 
muscles  due  to  abnormal  growth  of  the  pectoral 
glands. 

When  the  deeper  muscles  alone  are  involved 
(pleurodynia)  the  differential  diagnosis  will  be 
concerned  only  with  pleuritis  sicca  in  which  sharp 
pains  in  the  intercostal  region  are  also  a  prevail- 
ing symptom.  Intercostal  neuralgia  is  barred 
owing  to  the  peculiar  characteristic  of  the  pain 
and  tenderness  along  the  intercostal  space. 

In  the  differential  diagnosis  between  pleuro- 
dynia and  pleuritis  sicca  in  the  primary  as  well 
as  in  the  secondary  form  which  latter  may  arise 
from  a  morbid  condition  in  the  thoracic  wall, 
the  lungs  or  the  bronchi,  we  must  be  circumspect 
and  not  place  too  much  stress  on  what  the 


CHEST  213 

patient  tells  us.  He  is  wont  to  complain  of 
increased  painfulness  when  drawing  a  deep 
breath  or  during  coughing  or  sneezing.  He  will 
instinctively  put  his  hand  to  that  part  of  the 
thorax  in  which  the  pain  is  felt  when  the  urge 
for  such  respiratory  excursions  comes  on  and 
he  will  take  in  the  air  in  short  draughts  to  fore- 
stall pain.  However,  all  these  symptoms  may 
be  observed  in  every  form  of  thoracic  neuralgia, 
in  every  form  of  intercostal  neuralgia  as  well 
as  in  pleurodynia  and  pleuritis  sicca.  He  will 
also  tell  us  that  every  more  or  less  vigorous 
movement  of  the  thorax  engenders  the  same 
kind  of  pain — also  common  to  all  the  diseases 
aforesaid.  But  when  a  deliberate,  slow  move- 
ment provokes  the  pain  more  so  than  deep 
breathing,  we  may  take  it  as  a  pointer  in  favor 
of  intercostal  myalgia  or  neuralgia.  If  the 
thoracic  movement  towards  the  healthy  side  of 
the  body  strongly  exacerbate  the  pain  we  are 
dealing  with  a  tension  of  the  pleura  and  may 
incline  to  a  diagnosis  of  pleuritis.  In  intercostal 
neuralgia  the  same  kind  of  movement  towards 
the  affected  side  contracts  the  nerves  and  pain 
follows,  whilst  in  pleurodynia  (myalgia)  this  is 
not  the  case.  In  some  cases  the  faradic  current 
passing  through  a  moist  sponge  materially  as- 
sists the  diagnosis  of  myalgia,  because  under 
electric  treatment  the  pain  in  the  pectoral  mus- 
cles disappears. 


214  GENERALIZED   PAIN 

The  presence  of  local  tenderness  carries  no 
weight,  excepting  the  characteristic  pressure 
points  of  neuralgia.  Local  tenderness  exists 
in  intercostal  myalgia  as  well  as  in  pleuritis  sicca, 
but  if  it  extend  over  several  intercostal  spaces  it 
points  to  pleuritis.  Fever  exists  both  in  mus- 
cular rheumatism  and  in  fibrinous  pleuritis,  and 
both  may  have  the  same  etiological  genesis,  i.e., 
either  of  them  may  be  the  signal  of  acute  rheu- 
matism. Thus,  there  remains  only  one  more 
distinguishing  mark,  i.e.,  friction  fremitus  in  the 
pleura,  and  even  this  must  be  taken  with  caution 
unless  it  is  unmistakably  perceptible  in  its  typical 
form. 

We  can  hear  in  the  affected  part  a  fine  crepi- 
tant,  crackling  sound  with  inspiration  as  well 
as  expiration.  It  is  of  the  same  constancy  no 
matter  whether  the  patient  breathes  deeply  in 
the  regular  fashion  or  coughs.  It's  nature  is 
that  of  an  atelectatic  crepitus  caused  by  con- 
tinued superficial  breathing.  The  patient  could 
not  draw  a  deep  breath  if  he  wanted  to.  Erro- 
neously we  call  it  pleural  friction  fremitus.  I 
had  such  a  case  under  observation.  Crepitus 
was  distinct  and  constant.  The  patient  was 
much  relieved  by  the  application  of  a  compress. 
I  diagnosed  fibrinous  pleuritis  surmising  a  pul- 
monary infarct  due  to  demonstrable  arterio- 
sclerosis and  myofibrosis,  but  future  events 
proved  clearly  that  it  was  a  case  of  intercostal 


CHEST  215 

neuralgia  without  pressure  points  and  caused  by 
a  carcinoma  of  the  spinal  column.  This  shows 
that  even  a  definite  audible  crepitus  is  not  a  re- 
liable criterion  and  it  is  always  advisable  in  such 
cases  to  resort  promptly  and  at  the  earliest  possi- 
ble moment  to  the  electric  current  for  assistance. 

It  follows  that,  whenever  we  are  called  upon 
to  decide  whether  a  case  before  us  is  one  of 
pleuritis  sicca  or  of  unilateral  intercostal  neu- 
ralgia with  pressure  points  and  local  tenderness, 
we  should  make  a  thorough  examination  of  the 
spinal  column  and  of  the  ribs  and  ascertain 
whether  pain  reacts  more  intensely  to  thoracic 
movement  than  to  deep  breathing,  and  avoid  the 
palpable  error  of  a  diagnosis  of  pleuritis  sicca. 

Muscular  pains  in  the  chest  are  likewise  a 
sign  of  neurasthenia.  The  patient  is  in  fear  of 
a  heart  disease.  If  the  pain  is  aggravated  by 
movements  of  the  affected  muscle  but  is  miti- 
gated by  walking  the  diagnosis  is  readily  made. 

In  tetanus  these  pains  are  often  erroneously 
taken  to  be  of  a  pleuritic  nature,  while  in  reality 
they  are  due  to  morbid  contractions  of  the  pec- 
toral muscles. 

The  pains  released  in  the  chest  by  a  beginning 
grippous  affection  and  at  times  felt  in  the  initial 
stages  of  scurvy  are  at  least  in  part  due  to 
myalgia.  In  scurvy  they  are  also  caused  by 
hemorrhagic  condition  at  the  finals  between  the 
cartilage  and  the  osseous  section  of  the  ribs. 


216  GENERALIZED   PAIN 

Pectoral  when  combined  with  nuchal  pains 
(also  in  part  at  least  as  constituents  of  myalgia) 
may  be  furthermore  signs  of  a  chronic  septic 
infection. 

These  pains  in  the  chest  occasionally  come 
from  an  overexertion  of  the  abdominal  muscles 
in  severe  fits  of  coughing  because  their  terminals 
are  situated  in  the  bony  frame  of  the  thoracic 
wall. 

It  is  self-evident  that  a  fibrinous,  in  fact  any 
inflammatory  process  of  the  pleura  necessarily 
leads  to  pains  in  the  chest.  An  acute  tubercu- 
lous pleuritis,  it  is  true,  may  set  in  with  very 
mild  local  pains,  even  without  any  at  all,  but 
the  purulent  form  is  characterized  by  the  very 
intensity  and  constancy  of  these  molesting  con- 
ditions. Exceptions,  of  course,  are  parapneu- 
monic  and  metapneumonic  empyema. 

The  only  remaining  part  of  the  thoracic  wall  in 
which  pectoral  pains  may  originate  are  the  bones 
themselves,  mainly  the  ribs  and  the  sternum,  both 
of  which  I  shall  now  proceed  to  discuss. 

May  it  suffice  to  just  merely  mention  that 
these  two  skeletal  parts  may  be  affected  by  an 
acute  periostitis  or  osteomyelitis,  by  a  chronic 
tuberculous  (caries),  luetic  or  actinomycotic 
osteoperiostitis,  by  primary  or  secondary  neo- 
plasms, because  they  have  already  been  fully 
discussed  in  the  chapter  in  "Diseases  of  the 
Bones." 


CHEST  217 

But  I  will  apprise  the  reader  here  of  the  fact 
that  pains  in  the  chest  caused  by  primary  or 
secondary  neoplasms  of  the  bones  come  on  at 
times  most  abruptly  and  with  such  intensity  that 
deep  breathing  becomes  impossible  and  that  the 
patient  apprehensively  avoids  every  kind  of 
movement. 

In  vertebral  insufficiency  pains  in  the  chest 
are,  in  part  at  least,  attributable  to  the  spinal 
column.  For  diagnosis  and  symptoms  the 
reader  is  referred  to  the  volume  dealing  with 
"Abdominal  Pain." 

Pains  in  the  sternum  and  in  the  ribs,  the  same 
as  those  in  the  spinal  column,  may  be  only 
partial  manifestations  of  a  generalized  affection 
of  the  bones,  e.g.,  osteomalacia,  osteoporosis, 
rachitis,  multiple  primary  or  secondary  neoplasm 
or  myeloma.  (Details  will  be  found  in  the 
chapter  on  "Pains  in  the  Bones.")  For  differ- 
ential diagnostic  purposes  it  is  important  to  say 
that  these  pains,  similarly  to  those  in  the  muscles 
and  pleura,  are  aggravated  by  coughing  and 
sneezing,  etc.,  in  fact  coughing  frequently  starts 
them. 

In  chronic  myeloid  leucemia  we  find  exquisite 
tenderness  especially  in  the  thoracic  bones  which 
are  so  intense  that  the  patient  has  the  utmost 
difficulty  in  dressing. 

There  are  cases,  however,  of  this  last-named 
disease  in  which  the  pains  appear  rather  sub- 


218  GENERALIZED   PAIN 

dued,  or  may  be  missing  altogether  until  pro- 
voked by  pressure  and  palpation.  The  sternum, 
the  ribs  and  the  lower  extremities  are  by  prefer- 
ence the  seat  of  these  pains.  But  this  is  not 
unusual  in  other  diseases  such  as  severe  anemias 
of  primary  or  secondary  origin,  chlorosis,  Base- 
dow's  disease,  in  acute  phosphoric  poisoning,  in 
septic  and  pyemic  affections,  septic  endocarditis 
and  acute  leucemia.  A  valuable  hint  for  the 
diagnostician  ever. 

Malignant  neoplasms,  cold  abscesses  or  gum- 
mata,  also  arrosion  of  the  sternum  due  to  aneu- 
rysm  of  the  aorta,  etc.,  are  diseases  localized  in 
the  posterior  section  of  the  sternum.  The  clini- 
cal examination  shows  no  visible  or  palpable 
changes,  but  local  dullness  of  a  higher  degree 
may  be  noticeable.  Sternal  pain  and  local 
tenderness  are  present,  i.e.,  conditions  which 
strongly  resemble  those  enumerated  in  the  pre- 
ceding paragraphs  and  for  that  reason  deserve 
mention  in  this  place. 

A  special  form  of  sternal  pain  has  its  abode 
in  the  region  of  the  ensiform  appendix  and  is 
likely  to  remind  us  of  an  affection  of  the  syn- 
chondrosis  of  the  ensiform  cartilage  with  the 
corpus  sterni  often  enough  witnessed  as  a  par- 
tial manifestation  of  gonorrhoic  articular  rheu- 
matism or  of  a  gouty  diathesis.  A  fracture  or 
separation  of  these  two  bodies  due  to  some 
trouble  in  the  bony  skeleton,  e.g.,  osteoporosis  is 


CHEST  219 

also  a  possibility.  Chondrosis  and  perichondro- 
sis  of  the  aforesaid  cartilage,  with  local  tender- 
ness or  even  enlargement  (perhaps  of  syphilitic 
origin)  may  also  be  at  the  bottom  of  these  pains. 
Furthermore,  we  must  not  forget  that  girdle- 
pains  arising  from  any  irritation  or  inflamma- 
tion of  the  posterior  roots  of  the  upper  and 
median  dorsal  segments  may  be  focused  in  the 
region  of  the  ensiform  cartilage.  The  sole 
complaint  the  sufferer  makes  is  of  pains  at  the 
bottom  of  the  sternum,  i.e.,  the  ensiform  ap- 
pendix. 

Pains  behind  the  xiphoid  occur  in  aortalgia 
and  angina  pectoris.  These  attacks  come  on  as  a 
rule  with  bodily  exercise  and  produce  a  burning, 
pressing  painful  sensation  behind  the  ensiform 
appendix  with  a  tendency  to  gradually  climb 
upward  behind  the  sternum  into  the  left  arm. 
But  if  it  remains  stationaiy  we  must  be  prepared 
to  encounter  further  symptoms  of  epigastralgia. 

Pains  of  a  like  nature  supervene  also  in 
diseases  of  the  esophagus  and  cardia.  I  will 
speak  of  this  anon. 

It  is  rather  remarkable  that  this  investigation 
of  pain  is  not  always  a  correct  indication  of  the 
real  seat  of  the  disease.  The  patient  who  com- 
plains of  pains  thus  localized,  especially  during 
swallowing,  is  undoubtedly  suffering  from  car- 
cinoma of  the  esophagus.  But  this  carcinoma 
is  not  located  behind  the  ensiform  process,  but 


220  GENERALIZED    PAIN 

higher  up  on  a  level  with  the  middle  of  the 
chest.  The  pain,  therefore,  can  only  be  the 
reflex  action  of  esophageal  spasms.  Another 
patient  complains  of  the  same  kind  of  spastic 
pains,  he  can  pass  neither  fluid  nor  solid  foods. 
The  causative  factor  is  a  tumor  in  the  pyloric 
region.  The  painful  cardiospasms  are  the  reflex 
action  of  the  tumor. 

Pains  behind  or  close  below  the  xiphoid  pro- 
cess are  proper  to  gastroptosis,  no  doubt  due  to 
a  dragging  of  the  cardia.  They  come  on  after 
eating,  or  during  walking  or  going  upstairs. 

Pains  around  the  ensiform  appendix  are  com- 
mon in  diseases  of  the  diaphragmatic  muscular 
system.  When  associated  with  dragging  pains 
in  the  masseters,  beginning  trismus,  epigastric 
pains,  pulling  pains  in  the  extremities,  profuse 
sweating,  and  sleeplessness,  they  are  valuable 
symptoms  of  tetanus.  Later  on  they  pair  with 
diaphragmatic  shock. 

Within  a  narrow,  limited  zone  around  the 
sternum  certain  diseases  originate  which  cause 
very  painful  local  sensations.  I  refer  to  the 
affections  of  the  sterno-clavicular  joint  and  that 
which  connects  the  sternum  with  the  7.  rib.  The 
most  common  among  these  are  acute  articular 
rheumatism  and  gonorrhoic  arthritis.  Local 
swellings,  reddening  of  the  skin,  the  general 
symptoms  and  the  X-ray  will  steer  the  diagnosis 
into  a  safe  port  even  in  those  rare  cases  in  which 


CHEST  221 

the  two  aforesaid  diseases  settle  either  momen- 
tarily or  even  permanently  in  these  joints.  I 
must  add,  however,  aneurysms  of  the  aorta,  of 
the  anonyma  and  the  subclavian  arteries,  which 
are  offenders  in  the  same  sense. 

Pain  behind  the  sternum  should  direct  our 
eye  to  the  myocardium  and  the  aorta.  Acute 
and  chronic  aortitis,  sclerosis,  aneurysm,  insuffi- 
ciency of  the  aorta,  sclerosis  of  the  coronary 
arteries,  acute  and  chronic  pericarditis,  acute 
arteritis  of  the  anonyma,  are  distinguished  by 
the  fact  that  the  spontaneous  pains,  character- 
istic in  all  of  them,  are  provoked  by  bodily 
movements,  but  dormant  when  the  patient  is  at 
rest.  On  the  other  hand  in  acute  myocarditis, 
arteritis,  aortitis  and  pericarditis  the  pains  are 
of  a  constant  nature  in  the  region  of  the  heart, 
i.e.,  behind  or  lateral  to  the  superior  sternum, 
coupled  with  pronounced  local  tenderness  on 
pressure  and  palpation. 

In  true  angina  pectoris  the  pains  are  like- 
wise localized  behind  the  sternum.  ( See  chapter 
on  "Cardiac  Pains.") 

I  must  not  neglect  to  mention  thrombosis  and 
thrombophlebitis  of  the  vena  cava  superior  as 
a  possible  cause  of  later o- sternal  pains.  A  simi- 
lar pain,  resembling  rather  that  connected  with 
angina  pectoris,  may  also  be  provoked  by  an 
aneurysm  of  the  anonyma  when  it  expands 
downwards  inwardly.  The  patient  is  apt  to 


222  GENERALIZED   PAIN 

complain  of  pectoral  pain  in  the  direction  of 
the  right  shoulder  joint. 

Patients  suffering  from  stenosis  or  obliteration 
of  the  superior  vena  cava  complain  of  constring- 
ent pains  behind  the  anterior  wall  of  the  chest. 
The  diagnosis  should  be:  cyanosis  and  edema, 
and  collateral  expansion  of  the  superficial  tho- 
racic vessels  and  epigastric  veins. 

Sensitiveness  in  the  upper  sternum  and  the 
adjacent  intercostal  spaces  is  likely  to  be  induced 
throughout  the  intervals  between  the  attacks  of 
angina  pectoris.  It  springs  from  an  aneurysm 
of  the  aorta  with  or  without  arrosion  of  the 
sternum  or  from  any  other  form  of  mediastinal 
disease  that  gives  injury  to  the  posterior  sternal 
portion.  I  mention  morbid  conditions  of  the 
retro-sternal  antemediastinal  lymphatic  glands. 
In  tuberculosis  of  these  glands  painful  tender- 
ness chiefly  on  pressure  and  palpation  exists  in 
a  limited  zone  of  the  sternum  corresponding  with 
the  level  of  the  4.-6.  thoracic  vertebra.  Analo- 
gous pains  are  felt  in  syphilis  of  the  same  glands 
and  are  coupled  with  acute  inflammatory  or 
purulent  changes.  Anthracosis  of  the  peribron- 
chial  glands  with  perforation  into  the  air  pas- 
sages is  not  an  uncommon  incident.  Important 
for  the  diagnosis  is  the  presence  of  acute  or  sub- 
acute  putrid  bronchitis  (unilateral)  which  degen- 
erates into  an  abscess  or  gangrene  of  the  lung 
with  expectoration  of  sputum  which  shows  under 


CHEST  223 

the  microscope  a  free  layer  of  black,  crumby 
pigment;  there  is  dullness  over  the  superior 
sternum  or  laterally  to  it,  the  X-ray  shows  a 
shadowy  impression;  we  find  spontaneous  pain- 
fulness  over  or  laterally  to  the  manubrium  sterni 
with  tenderness. 

The  perforation  may  also  be  in  the  esophagus. 
If  it  is  latent  in  its  character  it  has,  as  a  rule, 
been  preceded  by  a  traction — diverticulum.  If 
infection  supersedes  the  diagnosis  will  be  mate- 
rially advanced  by  the  observation  of  pains 
behind  the  sternum  and  between  the  shoulder 
blades,  sensitiveness  in  the  spinous  processes  on 
palpation,  coughing,  pain  in  swallowing  behind 
the  manubrium  sterni  or  the  xiphoid  process, 
recurrent  paresis,  pupillary  difference  and  heav- 
ing up  of  evil  smelling,  caseous,  purulent,  bloody 
masses. 

This  list  would  be  incomplete  without  the 
inclusion  of  benign  and  madignant  tumors  of 
the  mediastinum  or  the  appertaining  glands, 
also  inflammations  thereof  (diffuse  or  localized 
mediastinal  abscesses  of  an  acute,  purulent  or 
sanious  character,  or  arising  through  continuity 
or  metastasis,  or  of  a  chronic,  indurated  or 
syphilitic  nature,  likewise  actinomycotic  medi- 
astinitis),  also  tumors  of  the  thynius,  substernal 
struma  with  strumitis,  carcinoma  of  the  bron- 
chus, mediastinal  pleuritis  and  pericarditis.  The 
same  manifestations  of  severe,  periodically  in- 


224  GENERALIZED   PAIN 

creasing  pains  behind  the  upper  sternum  or 
within  the  reach  of  the  intercostal  nerves  are 
individual  to  all  these  diseases  whether  they  are 
associated  with  an  affection  of  the  sternum 
proper  or  not. 

Of  course,  combinations  of  these  diseases  are 
not  impossible  and  we  may  well  anticipate  the 
presence  of  severe  retrosternal  pains  when  each 
of  them  separately  is  capable  of  producing  them. 

Carcinomata  of  the  lung  or  the  bronchus  call 
forth  severe  pains  which  resemble  neuralgia  very 
closely  and  radiate  into  the  arms.  They  arise,  in 
part  at  least,  from  the  aforementioned  glands, 
but  also  from  the  bronchus,  and  bear  the  char- 
acter of  pulmonary  infiltrating  carcinomata. 
The  clinical  picture  will  be  complete  for  diag- 
nostic purposes  when  we  observe:  irritating 
coughs,  want  of  thoracic  participation  in  the  act 
of  breathing,  dyspnea,  slight  involvement  of  the 
lungs,  general  indisposition,  absence  of  respira- 
tory sound  or  crepitus,  sputum  tinged  with 
blood,  metastasis  in  the  glands,  in  the  supra- 
clavicular  fossa  and  in  the  skin  and  sometimes 
subfebrile  temperature.  The  Roentgen-ray  is 
bound  to  render  good  service. 

We  will  turn  our  attention  now  to  the  trachea 
and  the  esophagus. 

Among  the  tracheal  pains  the  commonest  is 
that  observed  in  acute  as  well  as  in  chronic 
trachcitis.  There  is  a  feeling  of  dryness,  tick- 


CHEST  225 

ling,  burning  and  soreness  behind  the  sternum. 
There  is  cough  with  copious  expectoration,  a 
distinct  deficiency  of  bronchial  symptoms,  but 
decided  treacheoscopic  evidence.  A  complex  of 
unmistakable  symptoms  for  the  diagnostician. 
Sensitiveness  on  pressure  and  palpation  is  usu- 
ally absent,  but  the  pains  are  highly  sharpened 
by  paroxysms  of  coughing  which  may  also  be 
provoked  by  pressure  on  the  first  treacheal  ring. 
The  retrosternal  pain  in  pertussis  may  be  ex- 
plained in  the  same  manner,  and  likewise  that 
experienced  in  chronic  stenosis  of  the  windpipe. 

It  is  hardly  necessary  to  mention  that  foreign 
bodies  in  the  treacliea  cause  local  pain.  Re- 
peated paroxysms  of  coughing  and  attacks  of 
suffocation  and  gagging  indicate  their  presence 
as  well  as  the  existence  of  a  subsequent  purulent 
or  sanious  tracheitis,  if  the  anamnesis  has  not 
already  given  us  the  required  information.  The 
arrival  of  the  substance  in  the  windpipe  or  in 
one  of  the  bronchi  and  its  expulsion  or  removal 
are  connected  with  retrosternal  pains,  no  doubt 
caused  by  an  injury  to  the  mucous  membrane. 
Similar  retrosternal  pains  are  also  the  compan- 
ions of  other  morbid  tracheal  or  bronchial  affec- 
tions, such  as  syphilis  or  carcinoma. 

A  perforation,  e.g.,  of  an  esophageal  carci- 
noma into  the  windpipe  also  releases  retrosternal 
pains  combined  with  local  tenderness  owing  to 
mediastinitis  produced  by  the  disease. 


226  GENERALIZED    PAIN 

Bronchial  asthma  confronts  us  likewise.  The 
pains  come  in  sudden  attacks  behind  the  sternum 
and  are  a  collateral  manifestation  of  the  periodic 
paroxysms,  and  are  undoubtedly  due  to  spasms 
in  the  bronchial  and  tracheal  muscles  and  to 
acute  hyperemia  of  the  mucous  membranes. 

In  broncholithiasis  the  pains  in  the  chest  are 
very  vicious  and  insufferable.  Spasmodic  cough- 
ing similar  to  whooping  cough,  dyspnea,  the 
sensation  as  if  a  lump  were  rising  and  falling 
in  the  windpipe,  periodical  hemoptysis  and  the 
final  expulsion  of  the  stone  are  clear  indications. 

It  is  needless  to  say  that  the  inhalation  of 
poisonous  fumes  irritates  the  air  passages  and 
causes  severe  local  pain.  Chlorine,  brass,  zinc 
and  the  terrible  gases  employed  in  warfare  are 
striking  examples. 

Diseases  of  the  esophagus  proper  are  fre- 
quent factors  in  retrosternal  pains.  Soup,  coffee, 
tea,  milk  or  other  beverages  that  are  too  hot,  or 
a  morsel  of  food  that  is  too  large,  etc.,  may 
cause  severe  pain  and  even  injury  to  the  gullet. 
Analogous  painful  sensations  in  the  act  of  swal- 
lowing are  caused  by  inflammatory  processes  in 
and  around  the  esophagus  (esophagitis,  medi- 
astinal  pleuritis,  pericarditis,  mediastinitis,  etc.) ; 
by  every  possible  form  of  functional  or  organic 
stenosis  of  this  organ,  or  by  local  tumors.  In 
carcinoma  they  are  accompanied  by  local  tender- 
ness and  aggravated  by  deglutition  or  when  the 


CHEST  227 

patient  is  in  a  prone  position.  In  this  affection 
—but  not  exclusively — these  retrosternal  pains 
are  not  only  experienced  during  the  intake  of 
food,  but  may  be  present  constantly  and  more 
so  in  the  night  time.  Dysphagia  is  apt  to  prove 
a  fatal  complication.  A  deep-seated  esophegeal 
diverticulum  may  also  during  ravenous  eating 
cause  severe  pains  in  the  chest,  likewise  dyspha- 
gia  and  palpitation  of  the  heart.  Prompt  relief 
ensues  from  emptying  the  contents. 

In  peptic  ulcer  the  pain  is  generally  localized 
in  the  epigastrium  but  often  reaches  up  behind 
the  sternum  in  the  neighborhood  of  the  nipples. 
They  come  on  in  periodic  attacks  for  days  or 
weeks — the  same  as  is  the  case  in  ulcus  ventriculi 
or  duodeni — and  last  for  a  minute  or  hours  with 
remissions  and  intermissions  and  cycles  of  abso- 
lute painlessness.  Fairly  reliable  indications 
are:  when  the  patient  throws  up  profuse  masses 
of  blood,  when  swallowing  of  solid  food  and 
eventually  of  liquids  becomes  more  and  more 
difficult.  Of  course,  in  such  instances  the  dif- 
ferential diagnosis  lies  between  carcinoma  and 
intermittent  esophagospasm.  Radioscopic  ex- 
amination should  furnish  the  proof. 

In  the  diagnosis  of  esophagism  my  advice  is 
to  proceed  with  caution,  because  it  is  so  fre- 
quently the  consort  of  an  anatomical  lesion,  e.g., 
ulcus  or  carcinoma  of  the  esophagus. 

The  retrosternal  pains  which  accompany  that 


228  GENERALIZED   PAIN 

rather  rare  disease,  dysphagia  lusoria,  are  local- 
ized high  up  behind  the  sternum  and  are  due 
to  pressure  on  the  esophagus  by  the  right  sub- 
clavian  artery. 

Pyrosis  or  heartburn  is  another  offending 
member  of  this  family  of  pains  to  which  belongs 
also  a  whole  string  of  gastric  affections,  diseases 
of  the  liver,  the  pancreas  and  the  adrenals.  I 
have  already  touched  on  this  subject  in  the  chap- 
ter on  "Cardiac  Pains."  Our  mind  turns  auto- 
matically to  the  gastric  or  lower  esophageal 
region  when  a  patient  complains  of  pains  behind 
the  lower  third  of  the  sternum.  A  carcinoma  of 
the  heart  or  an  infiltrating  scirrhus  of  the  stom- 
ach naturally  give  rise  to  such  pains,  especially 
when  they  announce  themselves  during  meal 
time.  But  this  "warning"  localization  of  pec- 
toral pains  is  by  no  means  always  a  requisite 
sign  of  gastric  trouble.  The  pains  may  lie 
higher  up.  I  saw  not  long  ago  a  case  of  hour- 
glass stomach  in  which  the  patient  placed  the 
pains  behind  the  middle  of  the  sternum.  An- 
other patient  who  suffered  from  gastric  carci- 
noma told  me  that  when  going  down  hill  his 
whole  body  shook  with  pain.  The  same  hap- 
pened in  a  case  of  adhesive  perigastritis  of  the 
small  curvature.  In  stenocardia,  on  the  con- 
trary, this  motoric  pain  arrives  with  the  going 
up  hill. 

In   peracute    engorgement    of    the    liver    the 


CHEST  229 

patient  likewise  experiences  a  similar  motoric 
pain  and  also  pressure  in  the  retrosternal  region 
when  he  is  going  down  hill,  but  epigastric  and 
dextrohypochondral  painful  sensations  are  also 
present.  (Cf.  volume  on  "Abdominal  Pain.") 

Some  patients  suffering  from  liver  colic  local- 
ize the  pain  immediately  behind  the  sternum,  i.e,, 
the  lower  median  region,  or  about  the  height  of 
the  2.  rib,  with  less  intensive  pain  behind  the 
right  costal  arch.  For  a  proper  diagnosis  it  is 
important  to  note — especially  in  a  differential 
diagnosis  of  angina  pectoris — that  the  patient 
does  not  quite  correctly  localize  the  pain  as  being 
behind  the  sternum,  it  is  more  to  the  right  of 
it  on  a  level  with  the  mamma  or  nipple,  also 
that  he  experiences  no  motoric  pains,  unless  it 
be  during  the  night,  that  he  finds  relief  with 
flatus,  that  the  liver  is  enlarged,  that  the  urine 
contains  urobilinogen  or  urobilin,  that  we  find  a 
slight  rise  in  the  temperature,  pressure  pain  in 
the  cucullaris  on  the  right  side  and,  perhaps, 
icterus. 

The  last  three  of  the  aforesaid  symptoms 
suffice  sometimes  to  make  the  diagnosis  positive 
in  those  rare  cases  of  colica  hepatica  calculosa  ( I 
have  seen  three  of  them)  in  which  exclusive 
pains,  and  very  light  at  that,  are  felt  behind 
the  sternum  or  simultaneously  also  to  the  right 
or  left  of  it. 

From   my   own-  experience   I   can   say   that 


230  GENERALIZED   PAIN 

oppressive  pains  behind  the  sternum  2  hours 
after  eating  and  also  after  some  psychic  excite- 
ment may  well  be  accepted  as  a  symptom  of 
chronic  cholelithiasis. 

This  selfsame  disease  may  furthermore,  run 
its  course  with  boring,  stitching  and  oppressive 
pains  in  the  chest  and,  perhaps,  in  the  back. 
Sensitiveness  on  pressure  in  the  region  of  the 
fissure  of  the  liver  is  a  valuable  hint. 

Ulciis  duodeni  produces  the  same  kind  of 
pain  as  hepatic  colic,  but  exclusively  behind  the 
sternum  and  to  right  and  left  of  it  in  the  nipple 
line.  We  find  minor  tension  in  the  upper  right 
rectus,  tenderness  on  deep  prodding  palpation 
to  the  right  of  the  median  line  near  to  the  gall- 
bladder, hyperesthesia  of  the  skin,  the  latter  also 
in  the  back  on  the  right  side  of  the  spinal 
column  over  the  12.  vertebra;  likewise  hyper- 
acidity, hypersecretion,  gastrectasis,  possibly  oc- 
cult hemorrhages  in  the  intestine,  and  a  very 
instructive  Roentgen  picture. 

Addison's  disease  harbors  pains  which  are 
felt  oppressively  behind  the  sternum  some  time 
after  eating.  The  diagnosis  is  not  difficult  to 
make  from  the  typical  symptoms  of  the  ailment. 

Similar  pains  are  noticeable  in  disease  or 
insufficiency  of  other  internal  secretory  glands, 
e.g.,  in  agenitalism  or  hypogerutalism.  They 
frequently  cause  sleepless  nights.  The  same 
may  be  said  of  Basedow's  disease,  which  should 


CHEST  231 

always  remind  us  of  a  substantial  struma  or  an 
enlargement  of  the  thymus  as  the  possible  cause 
of  the  pain. 

We  must  reckon  with  an  expanding  subdia- 
phragmatic  morbid  process,  especially  of  the  liver 
(abscess  of  the  liver,  echinococcus  cyst  below 
the  diaphragm,  large  gummata  or  carcinoma- 
tous  growths),  when  the  patient  complains  of 
an  unpleasant,  incommoding  feeling  behind  the 
sternum. 

Neurosis  in  the  form  of  nosophobia  is  distin- 
guished by  pains  which  are  felt  only  in  a  very 
limited  part  of  the  sternum.  We  may  observe 
it  in  neurasthenic  people  who  have  suffered  an 
acute  psychic  shock  or  are  eshausted  by  over- 
exertion  in  mental  work  after  a  previous  attack 
of  syphilis.  It  is  not  uncommon  among  medical 
men  who  are  liable  to  make  an  individual  erro- 
neous diagnosis  of  sclerosis  of  the  coronary 
arteries,  or  of  an  aneurysm  of  the  aorta,  or  even 
a  retrosternal  gumma.  The  negative  Roentgen 
picture,  negative  clinical  findings,  repeated  nega- 
tive Wassermann  reaction  and  the  proof  that 
the  pains  are  not  due  to  physical  overexertion 
but  rather  to  a  mental  strain,  soon  calm  the  mind 
of  the  patient  and  remove  the  pain. 

In  anginoid  conditions  it  is  not  pain  so  much 
than  a  feeling  of  oppressive  constriction  behind 
the  sternum,  that  is  felt  by  the  patient.  If  this 
sensation  combines  with  a  similar  feeling  in  the 


232  GENERALIZED   PAIN 

throat  it  bears  another  meaning  for  the  particu- 
lars of  which  I  refer  the  reader  to  "Pains  in  the 
Neck." 

Asthmatic  people  complain  of  sensations  such 
as  are  described  above. 

In  chronic  indurated  mediastinitis  the  Oliver- 
Cardarelli  sign  and  the  Roentgenogram  are  both 
of  value.  Pain  is  of  minor  significance  because 
it  is  very  faint,  but  there  is  a  sort  of  timid, 
incommoding  feeling  behind  the  sternum  to- 
gether with  slight  signs  of  dysphagia. 

A  similar  molesting,  oppressive,  retrosternal 
sensation — I  agree  with  Rosenbaclis  theory — is 
often  experienced  by  people  who,  for  instance, 
bend  over  a  desk  for  a  long  time  when  engaged 
in  strenuous  work.  They  breathe  little  and 
superficially,  forget  it  almost,  so  to  speak,  and 
are  forced  to  take  in  quick  and  deep  draughts 
every  now  and  then.  An  oppressive  strain 
makes  itself  known  near  the  xiphoid  process 
and  in  the  adjacent  sternum,  in  the  neighboring 
parts  of  the  chest,  in  the  muscles  of  the  neck 
of  the  lower  thorax  and  the  abdomen.  Whether 
the  triangular  muscle  of  the  sternum  is  involved 
is  a  mere  matter  of  speculation.  In  fact  we 
have  no  knowledge  of  any  disease  by  which  this 
muscle  is  affected. 

When  the  pains  are  localized  not  behind  but 
at  the  side  of  the  sternal  margins  with  local 
sensitiveness  we  should  be  on  the  lookout  for 


CHEST  233 

hysteria.  It  is  well-known  that  the  parasternal 
pressure  points  form  an  important  hyperalgesic 
region  for  the  diagnosis  of  this  disease. 

Neuritis,  possibly  also  neuralgia,  of  the 
phrenic  nerve  is  chiefly  the  sequel  of  diaphrag- 
matic pleuritis,  or  pericarditis  or  subdiaphrag- 
matic  peritonitis  or  perihepatitis  or  peripleuritis. 
It  is  characterized  by  a  pressure  point  in  the 
neck  between  the  sternocleidomastoid  and  the 
scalenus  anticus,  by  the  bouton  diaphragmatique, 
i.e.,  a  pressure  point  at  the  crossing  of  the  outer 
sternal  margin  and  an  imaginary  10.  rib,  also 
by  painfulness  on  pressure  along  the  9.  and  10. 
rib  on  a  level  with  the  line  of  attachment  of  the 
diaphragm,  and  finally  by  a  pressure  point  at 
both  sides  of  the  sternal  margins  in  the  first 
intercostal  spaces  and  laterally  from  the  spine. 

Morbid  affections  of  the  mediastinum  (bron- 
chial carcinoma),  mediastinitis,  also  diseases  in 
the  diaphragmatic  cavity  (spleen,  liver,  peri- 
toneum) often  cause  pain  behind  and  lateral 
from  the  sternum  with  or  without  involvement 
of  the  phrenic  nerve.  Whether  there  is  a  paral- 
lel idiopathic  neuralgia  of  the  phrenic  nerve  is 
uncertain. 

Pain  on  the  sides  of  the  sternal  margins,  some- 
times spontaneous,  but  always  on  pressure,  are 
often  the  sign  of  a  gouty  diathesis,  evidently 
due  to  gouty  changes  in  the  sternocostal  joints. 
The  diagnosis  must  be  based  on  the  presence  of 


234  GENERALIZED   PAIN 

tophi,  pains  in  the  tendon  sheaths  and  in  the 
articulations  (mostly  without  deformities),  skin 
affections  (itching,  chronic  eczema,  etc.),  diges- 
tive troubles,  hemorrhoids,  cramps  in  the  calves, 
renal  colic,  gouty  pains  in  the  feet  or  in  certain 
nervous  zones  (ischias)  preceding  acute  articular 
gout,  overrich  food,  sumptuous  living,  hereditary 
taint,  and  above  all  on  the  chemical  examination 
of  the  blood. 

Pain  in  the  chest  which  lies  beyond  the  ster- 
num directs  us  to  the  bronchial  and  pulmonary 
regions.  We  are  dealing  here  chiefly  with  pleu- 
rodynia. 

When  we  are  told  of  stitching  pains  in  the 
armpit  or  around  the  nipple,  especially  during 
coughing,  etc.,  we  shall  have  to  decide  between 
thoracic  myalgia,  intercostal  neuralgia  and  dry 
pleurisy.  Friction  fremitus  is  one  of  the  char- 
acteristic signs  of  dry  pleurisy.  But  friction 
fremitus  is  a  tricky  symptom  and  leads  to  many 
an  erroneous  diagnosis.  We  must  know  how  to 
distinguish  between  peritonitic,  perihepatic  and 
perisplenitic  friction.  It  is  either  a  primary 
inflammatory  morbid  process  of  the  peritoneum, 
mostly  of  a  tuberculous  nature,  or  it  is  caused 
chiefly  by  primary  diseases  of  the  liver,  the 
spleen  or  other  intraperitoneal  organs. 

In  endocarditis  (of  recent  origin  or  the  revival 
of  a  former  affection  of  the  heart),  especially 
in  endocarditis  lenta  the  false  diagnosis  of  dry 


CHEST  235 

pleurisy  on  the  basis  of  a  pulmonary  infarct  is 
most  frequently  made,  when  in  reality  it  is  a 
case  of  perisplenitis  on  the  basis  of  an  infarct 
in  the  spleen.  I  have  seen  a  diagnosis  of  left 
fibrinous  exudative  pleuritis  made  in  a  case  of 
unmistakable  leucemic  tumor  of  the  spleen 
coupled  with  fibrinous  perisplenitis  which  origi- 
nated from  myeloid  leucemia  and  a  large  soli- 
tary tubercle  of  the  spleen. 

The  deciding  point  in  such  cases  is  the  deep 
focal  seat  of  the  maxinal  distinctness  of  the 
friction  fremitus  just  beyond  the  lower  margin 
of  the  lung.  This  fremitus  is  often  perceptible 
away  high  up  in  the  lungs  and  cannot  always 
be  strictly  localized  within  distinct  limits.  If 
that  is  the  case  then  deep  palpation  and  the 
presence  of  maximal  sensitiveness  in  the  inter- 
costal space  below  the  inferior  pulmonary  bor- 
der will  come  to  our  assistance.  The  absence 
of  irritation  to  cough  is  only  of  problematical 
value,  because  this  may  be  observed  in  fibrinous 
pleurisy  as  well. 

It  is  scarcely  necessary  to  mention  that  dry 
pleurisy  is  a  complicating  element  in  the  major- 
ity of  pulmonary  diseases,  and  even  in  bronchitis 
when  this  approaches  the  pleura!  surface,  and 
that  it  is  often  the  natural  cause  of  pleurodynia. 
The  latter  is  also  observed  (in  the  10.  to  12. 
intercostal  space)  in  cases  of  independent  upper 
lobar  pneumonia,  when  the  pain  is  not  due  to 


236  GENERALIZED   PAIN 

pleurisy  but  is  rather  the  reflex  action  of  pain 
in  the  pectoral  muscles  or  those  of  the  diaphragm 
(phrenicus).  I  wish  to  point  out  also  that 
despite  the  central  localization  of  pneumonia 
(recognizable  only  by  the  aid  of  the  X-ray) 
pleurodynia  is  often  the  sign  of  a  pleural  in- 
volvement. 

Stitching  pains  in  the  left  side  are  frequently 
present  at  the  beginning  and  also  during  many 
infectious  diseases  and  are  due  either  to  peri- 
splenitis  or  to  an  acute  swelling  of  the  spleen 
with  painful  tension  in  the  splenic  capsule. 
Chronic  malaria  is  a  striking  example. 

The  same  quality  of  pain  adheres  to  acute 
empyema,  especially  in  the  interlobar  form;  like- 
wise to  diaphragmatic  pleuritis,  but  sharper  dur- 
ing deep  inspiration  and  coupled  with  dysphagia. 

When  a  patient  complains  of  such  stitches  in 
the  chest,  either  in  the  anterior  or  posterior,  es- 
pecially in  the  lower  sections  (in  a  line  with  the 
lower  intercostal  spaces)  or  near  the  borders  of 
the  costal  arches  and  sharpened  by  deep  breath- 
ing or  by  coughing,  we  must  look  for  a  fibrin- 
ous  and  exudative  inflammation  below  the  dia- 
phragm, especially  for  a  subphrenic  abscess. 
(Fuller  particulars  will  be  found  in  the  volume 
on  "Abdominal  Pain.") 

The  diagnosis  is  based  primarily  upon  the 
correct  differentiation  from  a  basal  pleuritis, 
because  both  have  in  common  diffuse  dullness, 


CHEST  237 

absence  of  Litten's  sign,  but  delicate  breathing, 
weakened  fremitus  and  consonance  of  the  voice, 
pleural  friction  at  the  upper  border  of  the  dull- 
ness. (Fuller  details  may  be  found  under 
"Pleuritis.") 

Similar  pains  reach  the  side  of  the  trunk  in 
acute  inflammatory  conditions  within  the  retro- 
peritoneal  space,  such  as  acute  pyelitis,  peri-  or 
para-nephritis.  Respiratory  complications  are 
not  unusual.  It  requires  the  most  painstaking 
examination  to  arrive  at  a  satisfactory  conclu- 
sion. 

When  the  pain  is  localized  chiefly  in  the  left 
side,  between  the  diaphragm  and  the  heart,  with 
a  sensation  of  fullness,  chronic  constipation  is 
indicated,  or  congestion  in  haustris  of  the  colon, 
distension  of  the  flexura  coli  linealis  (rarely  of 
the  flexura  hepatica),  which  severely  taxes  the 
left  diaphragm,  especially  when  local  adhesions 
are  present.  Free  and  copious  discharge  of 
gases  and  intestinal  contents  generally  brings 
relief  and  clears  the  diagnostic  aspect. 

Also  in  muscular  affections  of  the  diaphragm, 
we  find  pain  in  the  chest  and  sides,  particularly 
in  cases  of  influenza,  trichinosis  and  acute  poly- 
myositis.  Of  course,  in  trichinosis  the  pains  are 
essentially  due  to  the  invasion  of  the  respiratory 
muscles  by  the  trichinae,  but  the  fact  that  these 
pains  are  frequently  associated  with  difficulty 
in  breathing  and  even  attacks  of  suffocation, 


238  GENERALIZED   PAIN 

and  that  the  patient  has  a  dry  cough,  should  be 
sufficient  proof  of  diaphragmatic  involvement, 
especially  if  the  other  characteristics  of  the 
disease  are  carefully  studied.  Moreover,  the 
absence  of  Litten's  diaphragmatic  phenomenon, 
and  the  X-ray  picture  will  be  adjuvants. 

Overfatigue  from  gymnastic  exercise,  run- 
ning, racing  or  any  kind  of  sport  which  requires 
unusual  respiratory  action,  spasmodic  coughing 
or  sneezing  or  singultus,  violent  retching  or 
laughing  are  apt  to  cause  stitching  pains  in  the 
sides.  The  diagnosis  can  be  easily  made  when 
we  know  the  causative  factor,  when  the  pain 
ceases  with  rest,  and  we  can  find  no  abnormal 
conditions  in  the  organs.  Nevertheless,  we 
should  not  forget  that  the  primary  cause  may 
lie  in  hyperemia  of  the  liver  or  spleen. 

If  the  pains  continue  and  we  are  unable  to 
attribute  them  to  any  of  the  aforesaid  causes, 
we  should  turn  our  attention  to  subacute  or 
chronic  affections  of  the  pleura. 

Persons  who  have  had  pleurisy,  sometimes 
years  ago,  may  be  suddenly  attacked  by  violent 
pains  in  the  sides  when  panting  heavily  after 
running  or  some  specially  strenuous  physical 
exertion,  that  one  is  seriously  tempted  to  think 
of  a  return  of  the  original  disease,  possibly  due 
to  pleural  adhesions.  If  they  are  chiefly  local- 
ized in  the  lower  sections  of  the  lungs,  we  should 
look  for  weaker — sometimes  stronger — vesicular 


CHEST  239 

breathing,  atelectatic  crackling,  dullness  of  sound, 
change  of  vocal  fremitus  and  an  ever  perceptible 
rasping  noise  in  the  bronchi. 

Pleural  adhesions  may  also  be  the  after-effect 
of  a  former  injury  to  the  lung  (bullet,  bayonet, 
knife)  which  healed  up  with  a  smooth  surface 
of  the  skin.  The  clinician  may  surmise  its  pres- 
ence from  the  history  of  the  case,  but  he  cannot 
diagnose  it.  The  Roentgen  ray  is  the  only 
means  by  which  it  can  be  discovered.  This  is 
also  the  case  in  pleural  adhesions  which  have 
developed  after  pleural  puncture.  The  pains  in 
this  condition  are  very  severe  and  associated  with 
dyspnea,  agony  and  oppressive  feelings,  they 
are  all  over  the  chest,  no  matter  on  which  side 
the  patient  lies.  If  he  turns  on  the  sick  side, 
the  pleural  sinus  contractions  push  the  abdom- 
inal organs  downwards;  if  he  turn  to  the  other 
side,  they  are  pushed  upwards,  and  so  in  either 
case  there  is  painful  tension  on  the  adhesions. 

But  when  these  pleural  adhesions  are  local- 
ized in  other  than  the  lower  sections  of  the 
lungs,  the  diagnosis  is  beyond  our  ken.  Only 
the  Roentgen-ray  and,  in  marginal  adhesions  of 
the  heart,  i.e.,  in  pleuropericardial  adhesions,  the 
presence  of  cystolic  and  presystolic  contractions 
(of  the  apex  impulse,  or  of  a  certain  part  of 
the  precordia,  or  of  the  marginal  parts  of  the 
heart)  can  give  us  information.  These  contrac- 
tions, according  to  my  own  studies  on  the  sub- 


240  GENERALIZED   PAIN 

ject,  may  be  explained  on  the  ground  that  the 
lung  is  unable  to  fill  in  the  place  left  vacant 
by  the  shrinking  heart  owing  to  interference  by 
the  local  adhesions. 

But  not  all  pleural  adhesions  are  due  to  acute 
fibrinous  or  fibrinous-exudative  pleurisy  in  which 
long  continued  pains  are  suffered.  There  is 
another  form  which  is  not  adhesive,  but  also 
associated  with  persistent  pains  in  the  sides,  and 
which,  it  seems  to  me,  is  not  sufficiently  appre- 
ciated by  the  profession.  The  pain  as  well  as 
the  audible,  sometimes  even  palpable,  friction 
fremitus  is  due  here  to  enlargements  of  con- 
tiguous connective  tissues  which  rub  against  each 
other.  The  identification  of  large  pleural  ad- 
hesions should  offer  no  difficulty  when  a  thoracic 
contraction  cannot  be  explained  on  any  other 
basis  or  in  post-pleuritic  scoliosis  of  the  spine. 

It  is  much  harder  to  trace  to  their  origin 
these  severe  pains  in  the  breast,  coupled  also 
with  dyspnea,  which  are  due  to  a  chain  of  inter- 
lobar  cicatrices.  In  some  cases  it  is  utterly 
impossible  for  the  patient  to  lie  down.  Only 
the  Roentgen-ray  can  enlighten  us  in  this  con- 
dition. The  cicatricial  tissue  forms  a  solid  union 
between  the  mediastinum  and  the  lateral  wall 
of  the  thorax,  so  that,  no  matter  on  which  side 
the  patient  may  lie,  a  painful  tension  on  the 
cicatricial  cord  ensues. 

In  a  case  of  pleurisy — it  need  be  only  of  a 


CHEST  241 

serous  character — without  cytologic  conditions, 
in  which  complaint  is  made  of  very  severe,  in- 
creasing pains,  be  they  spontaneous  or  following 
a  pleural  puncture,  we  should  think  of  a  malig- 
nant neoplasm  in  the  pleura.  I  know,  on  ac- 
count of  the  slight  temporary  rise  in  the  tem- 
perature and  the  youthful  age  of  the  patient, 
the  diagnosis  in  these  cases  generally  reads: 
"Serous,  very  likely  tuberculous  pleurisy."  But 
in  the  course  of  a  few  weeks  a  slight  constric- 
tion of  the  posterior  and  lateral  sections  of  the 
thorax  manifests  itself;  the  intercostal  spaces  on 
the  affected  side  seem  to  have  grown  narrower. 
We  have  either  a  thick  pleural  induration,  with 
a  possible  exudate  behind  it,  or  a  malignant 
neoplasm  of  the  pleura  before  us.  Whenever 
the  regular  symptoms  fail  us,  i.e.,  absence  of 
metatastic  glands,  of  cachectic  edema,  of  ectasia 
in  the  superficial  veins  of  the  trunk,  of  thoracic 
edema,  or  absence  of  a  primary  tumor;  if  we 
cannot  find  an  hemorrhagic,  but  do  find  a 
serous  exudate,  and  no  cytologic  conditions  of 
diagnostic  value,  but  a  slight  upward  tendency 
in  the  temperature,  then,  and  in  that  case,  a 
complaint  of  severe  and  ever-increasing  pains 
in  the  affected  side  of  the  chest  should  awaken 
in  us  the  suspicion  of  a  neoplasm.  This  thought 
has  often  been  my  guide  in  making  a  correct 
diagnosis.  A  test  puncture  in  the  painful  zone, 
with  a  careful  laboratory  diagnosis,  will  forestall 


242  GENERALIZED   PAIN 

errors.  The  use  of  the  X-ray  should  not  be 
neglected. 

Subacute  or  chronic  actinomycosis  is  another 
condition  in  which  very  severe  pains  in  the  chest 
give  the  impression  of  a  pleuritic  affection. 
Here,  also,  we  find  a  tendency  to  the  formation 
of  very  extensive  constricting  pleural  indura- 
tions. With  this  possibility  before  us  we  are 
already  far  advanced  on  the  road  to  a  proper 
diagnosis.  A  local  puncture,  bacteriological  ex- 
amination and  the  complement  fixation  test  will 
do  the  rest. 

The  same  may  be  said  of  pleural  syphilis. 
If  the  W ' assermann  reaction  is  more  positive  in 
the  exudate,  if  such  exist,  than  in  the  blood, 
and  the  presence  of  spirochetes  in  the  exudate 
are  the  pillars  of  the  diagnosis. 

We  must  not  forget  that  even  a  feeling  of 
slight  oppression  or  of  fullness  in  the  chest  or 
pains  of  a  lesser  degree  in  the  side  may  indicate 
a  pneumothorax  that  has  developed  overnight, 
or,  perhaps,  a  sanious  empyema  or  a  pyopneu- 
mothorax,  all  of  which  are  causative  factors  of 
severe  painful  sensations. 

Not  only  the  vicious  character  of  the  pains, 
but  their  characteristic  localization,  on  the  right 
near  the  fourth  rib,  on  the  left  in  the  fifth  inter- 
costal space,  are  powerful  indications  of  a  spe- 
cial subordinate  form  of  pleural  exudation,  i.e., 
of  interlobar  pleurisy,  particularly  interlobar 


CHEST  243 

empyema.  In  addition  to  these  specific  pains, 
we  also  find  the  so-called  "suspended"  dullness 
in  the  interlobar  fossa,  or  in  a  part  thereof, 
displacement  of  the  heart  with  slight  dullness, 
and  what  I  call  the  paravertebral  circular  seg- 
ment. With  these  symptoms  and  the  aid  of  the 
Roentgen-ray  the  correct  diagnosis  is  bound  to 
evolve. 

Not  only  primary  affections  of  the  pleura, 
but  also  diseases  of  the  lungs  involving  the 
pleura,  give  rise  to  severe  stitching  pains  in  the 
chest.  In  the  presence  of  such  pains  our  mind's 
eye  is  naturally  directed  to  all  kinds  of  acute  as 
well  as  chronic  inflammatory  processes  in  the 
lungs,  including  acute  active  congestion,  new 
formations,  parasitic  growths,  the  diagnosis  of 
which  is  to  be  found  in  another  chapter  of  this 
book.  I  will  only  point  out  that  the  localization 
of  the  painful  focus  is  not  always  a  clinical  proof 
of  the  seat  of  the  disease.  In  croupous  pneu- 
monia, for  instance,  the  patient  generally  points 
to  the  healthy  side  as  the  seat  of  the  pain.  Per- 
haps anastosmosis  of  the  intercostal  nerves  must 
bear  the  blame  for  this  error. 

If  in  the  course  of  such  a  disease,  e.g.,  pul- 
monary echinococcus ,  the  hitherto  only  slight 
painfulness  should  turn  suddenly  into  an  attack 
of  very  severe  pleurodynia,  we  must  be  prepared 
to  find  cystic  suppuration. 

Moreover,   a   sudden   attack  of  pleurodynia, 


244  GENERALIZED   PAIN 

localized  in  a  specially  limited  area,  is  nearly 
always  the  symptom  of  a  small,  superficial 
pulmonary  infarct.  A  slight  acceleration  of  the 
breathing  act  and  the  cardiac  rhythm,  and  de- 
sultory participation  of  the  affected  part  of  the 
chest  in  the  respiratory  movements,  may  be 
noticeable.  The  localized  pleural  friction  may 
limp  behind  or  be  completely  corrected. 

In  pulmonary  tuberculosis  the  pains  are  most- 
ly felt  in  the  lobar  region,  and  are  generally  a 
sign  of  an  aftergrowth  which  has  reached  the 
surface  with  or  without  a  demonstrable  dry 
pleurisy.  These  pains  may,  however,  also  be  due 
to  a  complicating  attack  of  adhesive  pleurisy 
or  to  tension  from  pleural  adhesions. 

Morbid  conditions  of  the  mediastinum  or  of 
the  mediastinal  pleurae  are  further  causes  of 
pectoral  pain.  We  have  here  acute  fibrinous 
or  exudative  mediastinal  pleurisy,  not  unusual 
accompaniments  of  pneumonia  or  tuberculosis. 
The  latter  betrays  itself  by  systolic  friction, 
which  dies  away  at  the  height  of  the  inspirium. 

I  have  already  mentioned  that  sclerosis  of  the 
aorta  frequently  provokes  pressure  sensitiveness 
in  the  upper  intercostal  spaces.  I  wish  to  add 
here  that  similar  pains  occur  in  sclerosis  of  the 
intercostal  arteries  in  the  form  of  an  intermit- 
tent dyspragia. 

Aneurysms  of  the  aorta  and  mediastinal  tu- 
mors generally  settle  rather  in  certain  parts  of 


CHEST  245 

the  ribs  than  in  the  sternal  region.  The  patient 
complains  of  pain  in  the  mamillary  line,  with 
irradiations  in  the  back.  They  are  not  of  a 
constant,  but  rather  of  a  piercing,  more  or  less 
violent,  nature,  coming  on  in  successive  attacks, 
and  last  for  half  an  hour  or  so.  Analogous 
pains  between  the  sternum  and  the  nipples  oc- 
cur in  mediastinal  pleurisy,  and  may  continue 
during  the  whole  course  of  the  disease. 

The  fact  of  the  matter  is,  that  all  diseases 
which  cause  irritating  or  inflammatory  condi- 
tions in  the  posterior  spinal  roots  of  the  upper 
or  median  segment  of  the  thorax  will  also  give 
origin  to  girdle  feelings  around  the  chest  and 
to  pleurodynia. 

Insofar  as  mediastinal  tumors  are  concerned, 
I  animadvert  only  acute  or  chronic  affections  of 
the  mediastinal  lymphatic  glands,  particularly 
the  pulmonary  hilum  gland. 

I  have  repeatedly  seen  cases  of  acute  tonsillar 
infections  in  which  the  patient  complained  of 
piercing  and  shooting  pains  either  to  the  right 
or  to  the  left  of  the  sternum  in  the  second  or 
third  intercostal  space,  and  outside  the  para- 
sternal  line,  which  radiated  also  in  the  back. 
Local  pressure  and  signs  of  bronchitis  were 
present,  but  conspicuously  often  only  in  the 
region  of  the  upper  middle  lobes  around  the 
pulmonary  hilum.  I  think  there  is  good  reason 
to  attribute  these  pains  to  an  acute  swelling  of 


246  GENERALIZED   PAIN 

this  hilum  gland.  The  same,  no  doubt,  is  also 
the  case  when  the  patient  complains  about 
stitches  and  pressure  around  that  point  in  the 
presence  of  tracheitis  or  dry  bronchitis,  possibly 
combined  with  local  tenderness.  Signs  of  fibrous 
mediastinitis  were  never  observable  in  any  of 
these  cases,  and  I  am  certain  the  trouble  was 
due  to  defective  nasal  breathing,  or  chronic  ton- 
silitis,  if  not  to  an  analogous  infection  of  the 
lymphatic  pharyngeal  tissues.  The  Roentgen- 
ray  proves  of  extraordinary  value  in  such  cases. 

A  primary  bronchial  disease,  a  foreign  body 
or  stone  in  the  bronchial  tube  gives  rise  to  simi- 
lar pains  in  the  chest. 

The  pain  in  the  chest  which  is  experienced  by 
patients  afflicted  with  a  mitral  affection  during 
any  kind  of  bodily  motation  is  by  some  authors 
attributed  to  an  acute  congestion  of  the  bronchial 
mucous  membrane.  The  claim  is  made  that  the 
bronchial  veins  resp.  the  veins  of  the  medias- 
tinum are  so  congested  that  the  blood,  instead 
of  being  discharged  into  the  vena  cava,  runs 
back  into  the  cardiac  chambers,  and  in  this  man- 
ner produces  the  severe  pains  in  the  chest. 

In  hysteria,  spontaneous  pains  in  the  chest  are 
hardly  ever  observable,  but  pain  may  be  elicited 
by  pressing  the  finger  on  the  so-called  intercostal 
points.  This  tenderness  is  generally  found  at 
the  lower  margin  of  the  ribs,  about  two  inches 
in  front  of  the  anterior  axillary  line,  sometimes, 


CHEST  247 

however,  only  in  the  eighth  or  ninth  intercostal 
space. 

Subacute  or  chronic  diseases  of  the  diaphragm 
(hernia,  eventration)  are  frequently  the  cause 
of  pectoral  pains  which  may  be  mistaken  for  a 
symptom  of  pleurisy. 

Diseases  of  the  trunk,  of  the  intercostal 
nerves,  the  muscles  and  the  bones  are  apt  to 
give  rise  to  stitching  pains  in  the  sides.  In  fact, 
some  forms  of  metastatic  neoplasms  announce 
their  presence  through  them. 


A  special  form  of  complaint  is  observed  in 
patients  who  are  suddenly  visited  by  exceed- 
ingly boisterous  pains  in  the  breast.  Sometimes 
only  one  side  is  involved,  but  in  many  cases  the 
pain  goes  right  through  the  whole  of  the  chest, 
or  through  the  middle  field  thereof,  in  the  region 
behind  the  sternum  and  around  the  precordium. 
So  far  as  affections  of  the  heart  are  here  con- 
cerned, the  reader  will  find  a  satisfactory  account 
in  the  chapter  on  "Cardiac  Pains." 

I  mention  only  thrombosis  of  the  pulmonary 
artery  and  of  the  right  ventricle,  diseases  of  the 
mediastinum  and  sub  diaphragmatic  affections  as 
causal  elements  of  pectoral  pains. 

Embolism  of  the  pulmonary  artery  is  still  more 
culpable  in  this  respect  than  even  thrombosis. 

When  the  thrombus  settles  in  the  trunk  or  in 
the  main  branch  of  this  artery,  the  pains  come 


248  GENERALIZED   PAIN 

on  most  suddenly  together  with  an  enormously 
deep  pressure,  and  with  a  feeling  of  suffocation. 
The  diagnosis  can  be  made  without  fail  when 
we  can  promptly  and  properly  localize  the  seat 
of  the  thrombus,  i.e.,  in  the  right  ventricle  (in 
all  diseases  of  the  mitral  valves,  sometimes  in 
tricuspid,  also  in  arteriosclerosis  of  the  pulmon- 
ary artery),  or  in  peripheral  veins  of  the  body 
(in  puerperal  phlebitis,  phlebitis  and  phlebo- 
thrombosis  of  the  lower  extremities,  in  all  kinds 
of  infected  peripheral  wounds,  in  anal-resp. 
hemorrhoidal  veins,  etc.). 

Sudden  severe  pains  behind  the  sternum, 
coupled  with  anxious  moments,  may  indicate 
a  perforation  of  the  esophagus  (foreign  bodies, 
tumor,  scald  or  burns,  overtension,  rupture  in 
inveterate  drinkers),  or  a  suddenly  arising  com- 
munication between  the  gullet  and  the  windpipe 
(trachea,  large  bronchus).  The  bursting  in  the 
gullet  of  a  carcinoma  or  diverticulum,  mediasti- 
nitis  or  purulent  pericarditis  or  an  abscess  in  a 
dependent  part  are  some  of  these  causal  factors 
readily  portrayed  by  the  X-ray.  There  is  a 
sensation  as  if  "something  had  given  way"  in 
the  chest.  The  patient  complains  of  retrosternal 
pain  when  swallowing.  Food  in  its  passage 
causes  a  fit  of  coughing,  and  is  regurgitated. 

Similar  pains  may  be  observed  in  youthful 
individuals  who  have  suffered  from  fever,  ex- 
cessive sweating,  emaciation,  loss  of  appetite, 


CHEST  249 

distressing  irritating  coughs  or  intrascapular 
pains.  The  patient  generally  recovers  after 
having  thrown  up  some  ill-smelling,  bloody, 
purulent  phlegm  or  a  clod  of  blood  streaked 
with  pus  and  a  black  carbon  pigment.  In  some 
cases  a  localized  bronchitis,  broncho-pneumonic, 
gangrenous  or  caseous  pneumonic  focus  is 
formed,  caused  by  the  perforation  of  anthracotic 
or  tuberculous  mediastinal  glands. 

The  perforation  of  (mycotic)  aneurysms  of 
the  aorta  into  the  larger  air  passages  or  into 
the  gullet  is  generally  accompanied  by  pains  in 
the  chest,  but  they  are  of  lesser  intensity,  some- 
times missing  altogether  or  coupled  with  inter- 
scapular  pains.  Hemoptysis  and  subsequent 
death  from  suffocation  are  the  usual  result. 


II.  Pains  Only  in  One  Side  of  the  Trunk 

Here  the  trend  of  mind  is  turned  to  the  con- 
sideration of  various  morbid  processes  that  may 
exist  in  the  pleural  space,  not  to  speak  of  uni- 
lateral embolism  of  the  pulmonary  arteries  or 
infarction  of  the  lungs. 

Not  only  in  recent,  but  also  in  old,  cases  of 
fibrous  unilateral  pleurisy,  sudden  severe  pains 
in  the  chest,  with  dyspnea,  may  rise  to  the  sur- 
face. They  generally  go  away  gradually  in  the 
course  of  a  week  or  so,  owing,  I  think,  to  the 
rupture  of  a  pleural  adhesion  with  local  rupture 
of  the  lung  through  violent  coughing. 

Similar  pains  are  frequently  a  coexisting 
symptom  when  a  communication  between  lung 
and  pleura  is  being  formed.  This  may  take 
place  when  a  free  or  sacculated  purulent  or 
purulent-sanious,  sometimes  serous  pleuritis  or 
an  echinococcus  of  the  pleura  or  else  some  dia- 
phragmatic process  enters  the  lung  or  bronchus 
through  the  pleura.  We  generally  find  coex- 
isting acute  dyspnea,  typical  expectoration,  and 
even  pneumoihorax.  On  the  other  hand,  a 
pneumothorax  is  much  more  frequently  the  se- 
quel of  a  perforation  from  the  lung  into  the 
pleura.  The  diagnosis  should  evolve  from  the 

250 


CHEST  251 

typical    clinical    symptoms,    supported    by    the 
X-ray  picture. 

When  a  pulmonary  echinococcus  bursts  in  the 
pleural  cavity,  sudden  severe  pains  with  dyspnea, 
and  possibly  collapse,  are  the  natural  conse- 
quence. Of  course,  if  we  were  not  aware  of 
its  pre-existence,  the  diagnosis  might  be  a  rather 
complicated  matter.  But  the  Roentgen -ray 
should  reveal  the  true  state  of  affairs,  especially 
if  we  look  for  eosinophilia  of  the  blood  and  a 
supervening  urticaria. 

The  perforation  of  an  aneurysm  of  the  pec- 
toral aorta,  chiefly  into  the  left  pleural  cavity, 
is  always  associated  with  sudden  serious  pains 
in  the  chest  which  are  apt  to  radiate  also  into 
the  corresponding  shoulder.  The  general  clin- 
ical aspect  of  the  hemorrhage  should  suffice  for 
making  a  proper  diagnosis. 

Not  only  the  perforation  of  a  supraphrenic, 
but  also  that  of  a  subphrenic  organ  into  the 
pleural  cavity  gives  rise  to  such  pains,  but  only 
when  a  contraction  with  the  diaphragm  and  with 
the  diaphragmatic  pleura  existed,  and  not  with 
the  lung.  This  happens,  for  instance,  in  ab- 
scess of  the  liver  or  spleen,  in  gastric  tumors 
and  cancer  of  the  stomach.  The  formation  of 
a  pleural  empyema,  pyopneumothorax,  hemato- 
thorax  is  the  natural  result. 

When  a  trauma,  affecting  the  thorax,  has 
directly  preceded  the  onset  of  pain,  especially 


252  GENERALIZED   PAIN 

in  the  left  side,  we  must  think  of  a  possible 
diaphragmatic  hernia.  No  matter  whether  it  is 
congenital  or  acquired,  it  will  always  lead  to 
severe,  continuous,  though  fluctuating,  pains, 
which  may  even  reach  up  into  the  shoulders, 
when  stomach  or  intestines  or  both  protrude 
through  the  diaphragm  into  the  thoracic  space. 
If  the  hernia  is  acute  and  due  to  a  traumatic 
condition,  it  may  be  mistaken  for  a  pneumo- 
thorax.  The  Roentgen  portrait  will  clear  up 
the  situation,  and  also  show  the  differentiation 
between  hernia  and  eventration. 

It  is  well  to  remember  that  in  both  these 
morbid  conditions  the  pains  in  the  chest  are 
relatively  often  only  incidental;  I  mean  to  say, 
after  the  intake  of  food  when  the  stomach  is 
distended.  The  sensation  of  weight  on  the  chest, 
digestive  troubles,  and  palpitation  of  the  heart 
are  frequent  companions. 

The  perforation  of  a  subphrenic  organ,  or  the 
formation  of  subphrenic  abscesses,  pneumotho- 
rax  or  hematomata  (of  the  spleen  or  adrenals), 
also  a  sudden  hemorrhage  in  a  subphrenic  cyst 
originate  pains  in  the  abdomen  as  well  as  in 
the  lower  section  of  the  chest  (cf.  "Abdominal 
Pains").  The  anamnesis,  an  early  examination 
of  the  patient  and  the  evidence  of  internal  hem- 
orrhage should  remove  all  doubts  so  far  a?  the 
diagnosis  is  concerned. 

If  in  the  course  of  a  fibrinous  or  even  a  mild 


CHEST  253 

sero-eacudative  pleurisy  the  patient  complains  of 
sudden  severe  pain  in  the  chest  or  in  one  side 
thereof,  or  else  and  particularly  in  the  region 
below  the  left  costal  arches,  we  must  be  pre- 
pared to  encounter  an  attack  of  paresis  in  the 
left  side  of  the  diaphragm.  Here  we  find  sud- 
den pain,  periodically  labored  and  rapid  breath- 
ing, accelerated  pulse,  inhibition  of  the  left  tho- 
rax and  deficiency  of  Litten's  sign.  We  observe 
further  anteriorly  on  the  left  a  deep  tympanitic, 
full,  sonorous  sound  (not  unlike  that  in  pneu- 
mothorax)  which  ascends  to  within  the  fourth 
rib,  extending  to  the  middle  of  the  sternum  on 
the  right  into  the  median  axillary  line  on  the 
left.  Instrumental  percussion  is  positive,  there 
are  no  physical  defects  in  the  left  lower  posterior 
region  with  the  exception  of  pleural  friction  and 
a  minor  basal  pleuritic  dullness,  unless  a  parallel 
infiltration  of  the  left  inferior  lobe  exists  or  a 
dull  tympanitic  sound  is  heard  by  stronger  per- 
cussion over  the  left  lower  posterior  side  of  the 
primary  lesion.  The  heart  is  shifted  upwards 
toward  the  right.  This  clinical  picture,  which 
is  almost  the  type  of  an  acute  diaphragmatic 
eventration,  presents  many  features  of  a  saccu- 
lated  pneumothorax,  a  subphrenic  pneumotho- 
rax,  a  diaphragmatic  hernia  and  an  acute  dila- 
tation of  the  stomach.  That  the  Roentgen-ray 
can  give  valuable  information  is  self-evident. 
Of  course,  a  careful  clinical  examination  paves 


254  GENERALIZED    PAIN 

the  way.  Against  pneumothorax  is  the  unmis- 
takable tympanitic  character  of  the  percussion 
sound.  And,  again,  the  displacement  of  the  heart 
towards  the  right  and  upwards  differentiates  it 
from  pneumothorax.  As  for  subphrenic  pneu- 
mothorax and  diaphragmatic  hernia,  it  will  be 
observed  that  the  appurtenant  etiological  factors 
are  missing.  Acute  dilatation  of  the  stomach  is 
the  only  other  condition  that  craves  closer 
scrutiny. 

The  thought  of  an  acute  dilatation  of  the 
stomach  forces  itself  involuntarily  on  our  mind 
when  the  patient  suddenly  complains  of  an  at- 
tack of  severe  pain  and  weighty  oppression  in 
the  chest.  As  a  rule,  it  seems  to  me,  the  pain 
is  rather  localized  in  the  epigastrium  resp.  the 
left  hypochondrium.  Moreover,  the  upward 
tympanitic  tendency,  the  displacement  of  the 
heart,  the  other  physical  signs,  including  the 
pleximeter  symptom,  are  also  observed  in  acute 
diaphragmatic  eventration.  But  there  is  one 
moment  which  speaks  definitely  for  gastrectasis, 
viz.,  dry  vomiting.  The  necessity  to  remove  the 
stagnating  gastric  contents  with  the  stomach 
pump,  the  etiological  factor  and  the  quick  relief 
in  the  knee-elbow  position  soon  make  the  diag- 
nosis positive. 

Of  course,  there  may  be  complicating  circum- 
stances which  render  the  diagnosis  more  difficult. 
If  in  a  case  of  gastrectasis  the  patient  complains 


CHEST  255 

of  sudden  oppressive  pains  in  the  chest,  perhaps 
in  the  right  side  only,  we  must  not  be  surprised 
when  an  attack  of  acute  cholecystitis  (cholelithi- 
asis) is  under  way.  There  is  no  complaint  of 
hypochondralgia  or  epigastralgia  or  of  sudden 
retrosternal  stern  pain.  The  sensation  is  exclu- 
sively that  of  excruciating  pain  with  terrible 
oppression  in  the  breast.  If  the  reader  wishes 
to  get  fuller  details  of  the  diagnosis  he  will  find 
them  in  "Abdominal  Pain,"  under  "Hypochon- 
dralgia dextra." 

When  a  sudden,  most  excruciating,  splitting 
pain — the  patient  frequently  speaks  of  stitches 
in  the  side — is  experienced  in  the  lower  section 
of  the  lung  near  the  hypochondria  we  must  not 
forget  that  the  muscular  tissue,  and  not  the 
serous,  pleural  or  peritoneal  membrane  of  the 
diaphragm  is  the  most  likely  causal  factor.  I 
have  spoken  about  this  on  another  page  of  this 
book. 

In  conclusion  I  will  say  a  few  words  about 
that  apprehensive,  oppressive  feeling  in  the  chest 
nearly  always  coupled  with  labored  breathing, 
but  not  with  tangible  pain.  It  may  be  as  well 
to  let  all  the  originating  causes  of  this  condition 
pass  here  before  our  eyes  in  a  short  review. 
First  of  all  the  diseases  discussed  under  "Car- 
diac Pain"  are  worthy  of  mention.  These  are 
followed  by  the  morbid  conditions  which  affect 
the  thoracic  envelope  (skin,  muscles,  nerves, 


256  GENERALIZED   PAIN 

bones)  and  those  of  the  abdomen  (elevated  posi- 
tion of  the  diaphragm  or  painful  respiration!). 
They  will  be  further  discussed  in  the  section 
dealing  with  dyspnea.  A  similar  sensation  is 
also  experienced  in  cerebral  toxic  affections. 
Patients  afflicted  with  uremia  or  diabetes  speak 
of  it  as  a  feeling  that  comes  on  before  an  onset 
of  coma,  and  so  do  patients  who  are  distressed 
by  the  effects  of  narcotic  poisons  without  being 
stupefied  (chloroform,  morphine) ;  those  who 
suffer  from  shock  or  collapse  and  such  as  are 
in  a  pre-agonal  stage  and  yet  are  in  the  full 
possession  of  their  senses. 

I  may  be  allowed  a  final  remark.  There  are 
persons  who  pass  painlessly  through  an  illness 
which  is  as  a  rule  associated  with  most  intensive 
pains  in  the  chest.  I  do  not  wish  to  be  under- 
stood as  saying  that  this  is  due  to  a  physiologic 
subnormal  quality  of  sensibility.  The  patient 
is  rather  blessed  with  an  unwonted  anesthesia  of 
the  pleura  due  to  certain  pathological  conditions. 
As  an  illustration  I  mention  the  case  of  a  lady 
that  came  under  my  observation.  She  was  af- 
flicted with  tabes  dorsalis  and  passed  away.  The 
post  mortem  showed  a  severe  pleural  pneumonia. 
Another  female  patient  had  a  sanious  pyopneu- 
mothorax  due  to  the  perforation  of  a  gangrenous 
tuberculous  pulmonary  carcinoma.  Neither  of 
them  ever  uttered  a  single  word  of  complaint 
about  pain. 


Pains  in  the  Extremities 

If  pain  in  the  extremities  is  properly  localized 
in  the  muscles,  joints  or  bones  the  reader  will 
find  full  particulars  in  the  chapter  specially 
devoted  to  these  three  subjects.  But  if  the  pain 
cannot  be  rubricated  under  any  of  these  head- 
ings, then  it  is  very  likely  the  reflex  action  of 
pains  that  exist  in  some  other  part  of  the  anat- 
omy, unless  it  is  exclusively  confined  to  the 
extremital  regions. 

For  the  better  understanding  of  the  subject 
we  will  first  of  all  turn  to  the  study  of  pain 
which  is  localized  in  one  of  the  extremities  only. 

Its  field  of  action  may  be  in  the  skin,  a  mani- 
festation which  is  of  common  occurrence  in  many 
internal  diseases.  Demonstrable  skin  lesions  al- 
ways facilitate  the  diagnosis  very  considerably. 

The  first  in  order  is  erythema  nodosum.  Its 
favorite  place  of  attack  is  the  skin  in  front  of 
the  tibia  to  which  region  it  seems  to  be  rigidly 
confined.  Analogous  eflorescences  may,  how- 
ever, be  also  observed  around  the  knee  joints, 
the  thighs  and  forearms,  even  on  the  trunk  of 
the  body  and  in  the  face.  They  consist  of  mul- 

287 


258  GENERALIZED   PAIN 

tiple,  raised,  rosy  patches,  round  or  oval,  from 
one-half  to  three  inches  in  diameter  and  are 
exquisitely  tender,  tense  and  shiny.  The  condi- 
tion chiefly  occurs  in  children  and  delicate  young 
women. 

Sometimes  the  patient  complains  of  sponta- 
neous pains  in  these  patches  and  of  febrile 
attacks.  When  the  pains  radiate  into  limbs  and 
joints  the  disease  presents  the  features  of  a 
generalized  infection  with  an  acute  tumor  of 
the  spleen. 

This  affection  is  of  double  interest  to  the  in- 
ternist, because  it  frequently  follows  on  the  heels 
of  an  acute  angina,  or  is  the  accompanying 
symptom  of  articular  changes  in  articular  rheu- 
matism, a  fact  which  explains  its  ready  asso- 
ciation with  inflammatory  processes  in  the 
endocardium  or  pericardium.  To  my  mind  there 
is  no  doubt  that  erythema  nodosum  is  the  expres- 
sion of  a  bacterial  toxemia  or  bacteriemia  of  a 
different  kind  altogether,  and  we  must  not  be 
surprised  to  find  an  analogous  exanthema  during 
the  career  of  other  septic  diseases,  for  instance, 
in  phthisis  or  in  gonorrhea,  etc.  The  diagnosis 
should  offer  no  difficulties  as  it  is  easily  differ- 
entiated from  erythema  exudativum  multiforme 
which  is  confined  to  the  back  of  the  hands. 
Moreover,  in  the  latter  affection  we  miss  the 
severity  of  the  general  symptoms,  but  we  find 
a  tendency  in  the  patches  to  run  together  and 


EXTREMITIES  259 

spread  out  towards  the  periphery  (erythema 
gyratum,  herpes  iris),  and  the  fact  that  they  are 
absolutely  painless. 

It  might  be  more  difficult,  perhaps,  to  distin- 
guish erythema  nodosum  from  the  deuteropathic 
form,  especially  when  the  latter  sets  in  after  a 
septic  affection.  But  when  we  consider  the 
favorite  seat  of  the  patches,  the  benign  course 
so  typical  of  erythema  nodosum,  the  cytologic 
condition  of  the  blood  (always  normal  with  the 
exception  of  a  possible  slight  polynucleosis— 
so  far  as  I  am  aware  bacteria  have  never  been 
found  in  the  blood  in  this  disease)  and  the  co- 
existence of  septic  patches  of  a  different  char- 
acter in  the  skin,  no  doubts  should  arise  in  our 
mind  as  to  a  correct  diagnosis. 

In  anasarca  pains  in  the  extremities  are  not 
very  severe,  unless  the  onset  of  the  disease  is 
very  sudden  and  then  only  when  the  affected 
spot  is  exposed  to  pressure  or  friction  of  any 
kind.  This  is  also  the  case  in  edema  due  to 
thrombosis  of  the  vena  cava  inferior. 

It  may  be  of  interest  to  the  reader  to  mention 
here  that  I  have  seen  cases  of  anasarca  in  which 
the  skin  was  treated  by  drainage.  Several  quarts 
of  fluid  had  been  drawn  off  when  the  patient 
began  to  complain  of  pain  in  the  skin  at  the 
affected  spot,  which  molested  him  day  and  night 
for  a  considerable  while.  Even  paresthesias  were 
observed.  The  cause  for  these  pains  and  pares- 


260  GENERALIZED   PAIN 

thesias  is  not  yet  clear  to  me.  Neuritic  symp- 
toms? There  were  none.  Perhaps  it  was  the 
toxic  effect  of  the  concentrated  detritus  which 
remained  in  the  subcutaneous  cellular  tissue.  Or 
did  physical  changes  take  place  in  the  skin  itself? 
I  do  not  know. 

In  some  rare  cases  of  subacute  hematoma 
local  pains  in  the  limbs  have  been  observed. 
They  may  also  be  due  to  bedsores  on  the  heels, 
in  the  region  of  the  trochanters,  and  on  the  knee- 
joints,  likewise  to  furuncles  and  generalized 
furunculosis. 

Glanders  is  another  infectious  disease  which 
may  produce  painful  inflammations  on  one  of 
the  lower  extremities.  This  affection  is  fully 
discussed  in  various  other  sections  of  this  book. 

In  erythromelalgia  the  pains  in  the  extremities 
are  coupled  with  certain  changes  in  the  skin. 
The  characteristic  symptoms  of  this  disease  are 
reddening  of  the  skin  of  the  hands  (fingers)  and 
of  the  feet,  principally  of  the  big  toe  and  the 
heels,  severe  local  burning  pains,  perceptible 
swelling  in  the  affected  parts  and  copious  sweat- 
ing towards  the  end  of  the  sickness.  But  the 
pain  may  also  be  only  an  accompanying  symp- 
tom of  other  affections  such  as  Basedow's  dis- 
ease, or  chlorosis,  diseases  of  the  posterior  or 
lateral  grey  substance  of  the  spinal  cord,  of 
syringo,  tabes,  neuritis,  or  hysteria.  It  occurs 
likewise  as  a  combination  with  Reynaud's  dis- 


EXTREMITIES  261 

ease,  for  instance,  in  the  foot  of  nervous  indi- 
viduals who  suffer  from  chronic  nicotinism.  I 
speak  from  personal  experience.  I  have  also 
seen  a  case  of  erythromelalgia  on  the  right  foot 
coupled  with  sclerosis  of  the  arteries  of  the  right 
leg  and  foot,  also  caused  by  nicotinism.  The 
X-ray  confirmed  the  diagnosis. 

Furthermore,  diseases  of  the  internal  secre- 
tory glands  are  a  source  of  these  pains,  e.g., 
Addison's  disease,  myxedema  and  periglandular 
insufficiency. 

Similar  conditions  prevail  in  the  catatonic 
form  of  dementia  precox.  We  find  here  char- 
acteristic swellings,  reddening  and  cyanosis  ac- 
companied by  coldness  and  dampness  of  the 
extremities. 

Adipositas  dolor osa  or  Dercurris  disease  is 
characterized  by  irregular,  sometimes  symmetric, 
deposits  of  fatty  masses  in  various  portions  of 
the  body,  preceded  by  and  attended  with,  pain. 
It  is  chiefly  localized  on  the  exterior  side  of  the 
upper  arm,  in  the  region  of  the  deltoid  and  on 
the  leg  (sometimes  on  the  abdomen  but  never  in 
the  head,  in  the  face,  the  hands  or  feet).  When 
the  pains  are  localized  only  in  one  leg  of  a  very 
stout  person  the  diagnosis  may  be  in  doubt  as 
similar  pains  are  also  caused  by  phlebectasis. 
But  in  the  latter  case  the  pains  are  hardly  felt 
on  palpation,  if  at  all.  They  rather  manifest 
themselves  when  the  patient  is  standing  or  walk- 


262  GENERALIZED   PAIN 

ing,  but  are  modified  when  he  lifts  the  leg  up 
high  or  is  at  rest. 

Here  is  another  point.  Dercum's  disease  is 
often  attended  with  neurotic,  vasomotoric  and 
trophic  disturbances.  This  is  apt  to  lead  to  an 
erroneous  diagnosis  of  "neurosis."  Careful  pal- 
pation of  the  skin  should  forestall  the  mistake. 
Some  authors  claim  that  adipositas  dolorosa  is 
further  associated  with  sudden,  shooting  and 
cramp -like  pains  of  a  very  severe  character, 
especially  in  the  night  time.  I  have  never  been 
able  to  notice  it. 

The  features  described  just  now  are  attributed 
by  some  authors  to  painful  symmetrical  lipoma. 
Perhaps  not  without  cause.  But  in  lipoma  the 
pains  are  of  a  rheumatic,  gouty  character,  change 
about  from  one  place  to  another,  are  not  local- 
ized in  the  extremity  only,  but  affect  the  trunk 
as  well.  If  palpation  does  not  furnish  us  with 
satisfactory  evidence  for  a  positive  diagnosis, 
the  unusual  corpulence  of  the  patient  and  the 
attending  troubles  such  as  short  and  labored 
breathing,  palpitation  of  the  heart,  etc.,  should 
still  arouse  in  us  the  suspicion  of  a  painful  adi- 
positas. Moreover,  it  seems  to  me  that  in  many 
cases  of  symmetrical  lipoma  the  pains  consider- 
ably antedate  the  formation  of  the  fatty  tumor. 

Neurofibromatosis  of  the  skin  is  still  another 
source  of  the  pains  under  consideration.  They 
are  caused  by  the  formation  of  multiple  nodes 


EXTREMITIES  263 

in  the  subdermal  tissue  and  along  the  nerve 
trunks.  At  first  they  feel  to  the  touch  like 
pinheads,  but  later  on  may  assume  the  size  of 
a  plum,  are  very  painful  on  palpation  and  dis- 
tinguished from  those  typical  of  lipoma  by  their 
harder  consistence.  Besides,  abnormal  pigmen- 
tation and  thickening  of  the  skin,  and  trophic, 
vasomotoric  and  psychic  manifestations  are  fre- 
quent symptoms. 

I  must  not  forget  to  mention  erysipeloid,  a 
peculiar  affection  of  the  palms  of  the  hands  and 
soles  of  the  feet.  It  is  characterized  by  zones 
of  violaceous — red  eruptions  with  burning  and 
itching  and  due  to  wound  infection.  It  is  also 
met  in  persons  who  eat  meat  that  is  going  bad, 
high  game  or  overripe  cheese  or  any  kind  of 
unsound  food.  The  diagnosis  offers  no  obstacles. 

These  symptoms  at  once  establish  the  differ- 
entiation from  erysipelas  which  only  in  rare  cases 
attacks  the  upper  or  lower  extremities.  If  it 
does  the  patient  complains  of  heat  in  the  affected 
portion  and  the  pains  are  severe.  There  is  local 
reddening,  shiny  appearance  and  swelling  of  the 
sensitive  skin — the  patches  are  shaped  like  the 
wings  of  a  butterfly.  We  find  regional  enlarge- 
ment of  the  lymphatic  glands,  general  indispo- 
sition, chills  and  fever,  constant  thirst,  loss  of 
appetite  and  possible  complicating  conditions  in 
the  spleen  and  kidneys.  These  symptoms  should 
confirm  the  diagnosis  with  ease. 


264  GENERALIZED   PAIN 

It  will  be  more  perplexing,  however,  when 
we  have  to  differentiate  between  erysipelas  and 
phlegmon.  Of  course,  plegmonic  indurations 
are  harder  and  the  coloring  is  a  deeper  red,  but 
the  sharp  delineation  of  the  patches  is  the  distin- 
guishing feature  of  erysipelas.  We  may  en- 
counter another  difficulty.  Erysipelas  frequently 
originates  from  an  old  ulcer  of  the  leg,  the 
cutaneous  tissue  around  the  sore  is  very  much 
swollen  and  indurated,  the  patient  is  generally 
well  advanced  in  years  and  may  have  suffered 
from  previous  attacks  of  erysipelas.  In  conse- 
quence the  local  and  general  conditions  would 
show  different  characteristics.  The  red  tint  is 
paler,  the  local  swelling  is  less  pronounced,  and 
the  sharp  demarcation  of  the  patches  and  local 
sensitiveness  are  almost  wanting.  The  diagnosis 
must  here  be  guided  by  the  slow  progress  of  the 
disease  which  is  also  confined  to  a  much  nar- 
rower area,  the  want  of  distinctive  symptoms 
and  very  slight  rises  in  the  temperature.  In 
cachectic  and  anemic  patients  the  reddening  of 
the  skin  is  scarcely  perceptible,  but  local  sensitive- 
ness and  elevation  and  demarcation  of  the  cuta- 
neous tissue  are  typical.  The  name  of  erysipelas 
pallidum  is  here  applicable. 

Pains  in  the  extremities  may  also  be  due  to 
a  thrombosis  of  the  arteries  of  the  skin  on  the 
basis  of  syphilitic  or  local  endarteritis,  or  to  an 


EXTREMITIES  265 

embolism  of  the  same  vessels  in  bacterial  endo- 
carditis. 

Pains  in  the  fingers  and  hand,  also  rheuma- 
toid or  neuralgiform  pains  in  all  the  extremities, 
coupled  with  vasomotoric  crises  (blue  coloring 
of  the  ends  of  the  limbs,  cold,  hyperesthesia,  sud- 
den sweats)  and  fever  are  the  initial  signs  of 
sclerodermia  (sclerodactylia).  The  patient  dozes 
off  easily,  gets  hard  of  hearing,  feels  chilly  and 
is  molested  with  itching  in  the  fingers.  Such 
symptoms  should  arouse  our  suspicion.  The 
diagnosis  may  then  be  confirmed,  when  we 
observe  the  characteristic  thickening  and  harden- 
ing of  the  skin — it  is  glossy,  like  parchment, 
does  not  wrinkle  and  does  not  slide  about  over 
its  base.  If  similar  conditions  prevail  in  other 
parts  of  the  body,  the  diagnosis  is  still  easier. 
I  may  add  that  in  sclerodactylia  the  formation 
of  painful  trophic  ulcers  is  another  cause  of 
pain  in  the  fingers. 

Affections  of  the  superficial  nerves  are  bound 
by  their  very  nature  to  cause  neuritic  or  neu- 
ralgic pains  in  the  extremities.  Of  course,  there 
are  forms  of  neuritis  in  which  a  mixed  variety 
of  nerves  is  affected  but  without  motoric  symp- 
toms; and  again,  there  are  other  forms  which 
affect  only  the  sensitive  nerves,  i.e.,  they  provoke 
pain  with  or  without  paresthesias  but  no  motoric 
symptoms  whatsoever. 

Central  chiefly  spinal  disorders  which  usually 


266  GENERALIZED   PAIN 

lead  to  deep,  deeper  or  superficially  localized 
pains  in  the  extremities,  may  sometimes  mani- 
fest themselves  through  cutaneous  pains  only. 
Tabes  dorsalis  is  an  example.  The  pains  in  this 
disease  are  as  a  rule  of  a  lancinating,  dull,  deep- 
seated  character,  but  I  have  seen  cases  with 
superficially  localized  pains  in  the  skin  alone. 

Symptoms  similar  to  those  of  sclerodermia  we 
find  in  acroparesthesia,  in  conditions  of  over- 
fatigue,  in  neurasthenia  or  hysteria  and,  as  addi- 
tional signs,  in  various  other  diseases.  The 
patient  falls  asleep,  feels  cold,  has  creeping, 
stabbing  and  burning  sensations,  suddenly  turns 
pale,  one  or  more  fingers,  especially  the  tips, 
get  numb  and  icy — a  typical  sign  of  peripheral 
vasoconstriction. 

What,  however,  puts  the  typical  stamp  of 
idiopathic  neurosis  upon  acroparesthesia  is  the 
relative  frequency  of  the  nocturnal  attacks  due 
to  thermic  influences,  i.e.,  heat  and  cold.  They 
do  not  play  the  same  predominant  role  in  vaso- 
constricting  conditions  of  neurasthenia  and  hys- 
teria in  which  psychic  emotions  are  the  most 
frequent  causative  factors. 

In  speaking  of  deuteropathic  acroparesthesia 
I  will  mention  that  similar  paresthesias  in  the 
fingers  and  toes  are  often  accompanying  symp- 
toms of  osteomalacia  or  osteoporosis. 

If  these  pains  are  of  a  tearing,  stabbing 
nature  they  may  be  accepted  as  forerunners  of 


EXTREMITIES  267 

chronic    articular    rheumatism.      They    have    a 
nocturnal  and  early  matutinal  habit. 

In  anemic  and  wasting  diseases  they  again 
assume  the  part  of  accompanying  symptoms. 
I  refer  to  all  forms  of  secondary,  acute  and 
chronic,  anemias,  to  chlorosis  and  pulmonary 
phthisis.  Cold  hands  and  feet  and  drowsiness 
are  frequent  signs  in  all  of  them. 

In  arteriosclerosis,  in  chronic  myocarditis  and 
in  nephrosclerosis  they  are  important  additional 
symptoms  and  undoubtedly  provoked  by  over- 
stimulation  of  the  vessels. 

They  are  also  at  times  the  manifestation  in 
part  of  anatomical  disorders  of  the  central  ner- 
vous system,  e.g.,  tabes  or  multiple  sclerosis. 
Note  the  contrast  between  the  other  character- 
istic signs  of  this  disease  and  those  of  acro- 
paresthesia. 

In  diabetes  mellitus  these  paresthesias  in  the 
extremities  are  an  early  and  unmistakable  warn- 
ing, and  based  upon  some  sclerotic  vascular 
disorder  or  on  neuritic  conditions. 

In  migraine  they  are  the  directing  and  con- 
trolling element.  The  pains  seize  as  a  rule  both 
arms,  but  may  be  also  confined  to  one  only. 
The  pains  in  the  head  promptly  arrive  with  the 
vasomotoric  disturbances  in  the  arms.  Of  course, 
other  vasomotoric  manifestations  are  by  no  means 
excluded,  e.g.,  peripheral  angiospasm,  sweats 
and  vesicular  formations  in  the  skin. 


268  GENERALIZED   PAIN 

In  epilepsy  pretty  well  the  same  conditions 
prevail.  We  must  make  a  distinction  here  be- 
tween a  sensible  and  vasomotoric,  and  a  vaso- 
motoric  and  sensible  epileptic  aura.  In  the 
sensible  and  vasomotoric  form  the  sensible  aura 
is  recognized  by  paresthesias  or  pains  in  the 
extremities  which,  starting  at  the  distal  parts, 
rise  to  the  center,  and  the  vasomotoric  is  distin- 
guished by  simultaneous  vascular  spasms  coupled 
with  hyperesthesia  (hyperesthesia  angiospastica). 
It  is  not  difficult  to  identify  this  form  because 
in  it  the  characteristic  epileptic  convulsions  with 
loss  of  consciousness  develop. 

The  diagnosis  of  the  so-called  vasomotoric 
epilepsy,  on  the  other  hand,  is  beset  with  diffi- 
culties. The  vascular  convulsions  involve  most, 
if  not  the  whole,  of  the  system.  The  attack  is 
confined  to  the  limbs  only  although  it  may  have 
its  starting  point  there.  Sweating  is  profuse, 
the  temperature  high  and  secretion  of  urine  is 
reduced;  if  loss  of  consciousness  also  supervenes, 
the  diagnosis  is  simple  enough.  Our  difficulties 
begin  when  these  manifestations  are  accompanied 
by  the  so-called  psychic  epileptic  element.  The 
same  conditions  present  themselves  in  the  sen- 
sible form  of  this  disease.  The  patient  com- 
plains of  a  sudden  creeping  sensation  as  if  ants 
were  crawling  over  him.  This  always  starts  in 
the  same  extremity  gradually  extending  over 
the  whole  side  of  the  body  and  reaching  over  to 


EXTREMITIES  269 

the  other  half.  The  patient  does  not  know  for 
the  moment  where  he  is,  but  in  a  short  time 
recovers  himself  and  the  fit  is  over.  A  proper 
and  thorough  anamnesis  is  a  wonderful  support 
in  making  the  diagnosis. 

It  is  a  matter  of  common  knowledge  that 
paresthesia  attended  with  vasomotoric  manifes- 
tations in  the  distal  parts  of  the  extremities, 
especially  in  the  fingers,  is  the  usual  initial  symp- 
tom of  oncoming  convulsions  in  tetany  (gastric 
tetany  included).  When  the  convulsions  with 
the  typical  obstetric  position  of  the  hand  follow 
immediately  behind  the  sensible,  vasomotoric 
disturbances,  the  diagnosis  is  assured,  particu- 
larly so  when  we  observe  the  other  characteris- 
tics, i.e.,  facial  phenomena,  Trusseau's  or,  per- 
haps, ScTile singer 's  sign,  and  mechanical  or  elec- 
tric sypersensibility  of  the  nerves.  It  is  these 
very  symptoms  which  differentiate  attacks  of 
tetany  from  similar  pseudotetanic  actions  in  hys- 
teria. Note  also,  that  in  hysteria  the  facial 
phenomenon  may  be  arrested  by  giving  the 
facial  nerve  a  hard  blow  or  applying  some  other 
harsh  mechanical  force  to  it. 

In  tetany  Trousseau's  sign  may  produce 
paresthesias  without  spasms  resulting  from  the 
mechanical  pressure. 

There  are  also,  what  I  take  the  liberty  of 
calling  frustraneous  forms  of  tetany  or  tetanoid 
conditions  in  which  the  patient  complains  of 


270  GENERALIZED   PAIN 

periodical  attacks  of  paresthesia  in  the  extremi- 
ties. That  they  are  a  rudimentary  form  of  this 
disease  may  be  confirmed  by  the  fact  that  the 
majority  of  persons  who  suffer  from  genuine 
tetany  suffer  from  these  attacks,  e.g.,  cobblers 
and  tailors;  also  they  like  tetany  itself  are  usu- 
ally observed  in  the  springtime  of  the  year  and 
in  places  in  which  the  malady  is  endemic.  The 
symptomatology  given  above  applies  here  in  like 
measure,  excepting,  however,  Trousseau's  sign. 

Acroparesthesias  and  pains  in  the  extremities 
especially  in  the  hands  may  be  solitary  symp- 
toms of  latent  tetany,  in  which  there  are  no 
classic  tonic  muscular  spasms.  But  Trousseau's, 
Chvostek's  and  Schlesinger's  phenomena  and 
mechanical  and  electric  hypersensibility  of  the 
nerves  are  the  betraying  symbols. 

Whether  the  paresthesias  observed  in  the  ex- 
tremities of  pregnant  women  are  the  expression 
of  tetany,  i.'e.,  a  lesion  of  the  epithelial  bodies 
caused  by  the  gravid  state,  is  questionable. 

In  paroxysmal  tachycardia  the  same  condi- 
tions prevail  as  in  tetany  and  epilepsy,  sometimes 
on  one  side  only — an  aura  of  the  attack. 

Sudden  attacks  of  paresthesia,  preferably  in 
the  left,  but  at  times  also  in  the  right  upper 
extremity,  arising  in  various  cardiac  diseases, 
bear  a  different  meaning.  When  coupled  with 
an  oppressive  feeling  in  the  chest,  with  tachy- 


EXTREMITIES  271 

cardia  and  pallor  of  the  face  they  are  the  sign 
of  angina  pectoris,  but  there  are  no  pains  in  the 
chest  or  in  the  left  arm.  (Cf.  "Cardiac  Pain.") 
For  the  prognosis  they  are  of  lesser  significance. 
The  patient  may  suddenly  succumb  without  a 
sign  of  a  typical  attack  of  stenocardia,  while 
severe  anginose  attacks  may  repeatedly  come  on 
throughout  the  period  of  many  years. 

Occupation  neurosis,  writers'  and  pianoplay- 
ers'  cramps  are  caused  by  overexertion  of  the 
hands  and  fingers.  There  are  no  motoric  dis- 
turbances. Pains  and  paresthesia  in  the  limbs 
are  the  only  symptoms. 

Reynaud's  disease  (symmetrical  gangrene  and 
local  asphyxia)  is  characterized  by  peripheral 
vasoconstriction,  pallor,  coldness,  the  so-called 
dead  fingers  and  toes  with  intensive  pains.  We 
find  strongly  marked  sensibility  disturbances 
(hyperalgesia,  hypesthesia  and  anesthesia),  a 
livid  blue  or  bluish-black  coloration  and  symmet- 
rical gangrene  of  the  affected  parts.  It  may 
exist  as  an  independent  disease,  but  it  also  may 
be  a  secondary  or  associated  symptom  of  other 
affections,  such  as  diseases  of  the  nervous  system, 
or  of  the  spinal  cord  (tabes,  syringomyelia,  etc.), 
the  individual  symptoms  of  which  should  mate- 
rially assist  in  arriving  at  a  satisfactory  conclu- 
sion. But  note,  that  in  these  cases  gangrene  is 
not  symmetrical.  I  must  add  also  sclerodermia 
(sclerodactylia),  Basedow's  disease  and  hysteria. 


272  GENERALIZED   PAIN 

Extremity-paresthesia  is  sometimes  the  fore- 
runner of  Quincke's  edema,  e.g.,  of  the  hands. 

Chronic  kypertrophic  acroasphyxia  is  a  dis- 
ease which  has  only  recently  come  under  obser- 
vation. Its  distinctive  features  are  a  slowly 
progressive  asphyxia  of  the  distal  ends  of  the 
extremities  with  extension  into  the  softer  tissue 
at  the  same  places.  These  swellings  are  sym- 
metrical in  form,  very  seldom  unilateral.  Pale- 
ness, cold  hands,  at  times  painless  and  hardly 
ever  sensitive.  Differentiation  between  hysteria 
and  syringomyelia,  and  between  acromegaly  and 
osteoarthropathy  is  required  for  a  proper  diag- 
nosis. 

In  organic  nervous  diseases  it  is  rather  the 
paresthesias  accompanied  by  vasomotoric  mani- 
festations, than  the  pains,  that  play  the  predomi- 
nant role.  We  must  not  forget,  however,  that 
even  the  slightest  mechanical  strain  or  pressure 
on  a  nerve  trunk  is  liable  to  elicit  paresthesias, 
for  instance,  when  sitting  we  cross  one  leg  over 
the  other.  As  a  rule  no  significance  is  attached 
to  them,  unless  it  be,  that  in  neurasthenics  they 
occur  more  frequently  and  more  easily  than  in 
normal  people,  for  instance  the  hands  go  to 
sleep,  pins  and  needles  in  the  fingers,  upon  the 
slightest  pressure  on  the  nerve  trunks.  It  is  a 
different  matter  altogether  when  these  manifes- 
tations set  in  whilst  the  body  is  kept  in  one  and 
the  same,  even  quite  natural,  position  for  an 


EXTREMITIES  273 

unconsciously  long  time.  I  have  seen  cases  of 
aneurysm  of  the  aorta  in  which  the  patient  never 
complained  of  pain  or  paresthesia  in  the  right 
upper  leg.  But  as  soon  as  he  turned  on  his 
right  side,  they  would  promptly  appear  and 
molest  him  so  that  he  could  not  go  to  sleep. 
The  apparent  cause  was  undoubtedly  the  shift- 
ing of  the  aneurysm.  We  may  find  herein  a 
hint  that  phenomena  of  this  kind  are  likely  due 
to  the  pressure  of  some  organic  lesion  in  the 
nerves. 

These  purely  functional  changes  in  the  peri- 
pheral nerves  pave  the  wuy  directly  to  those 
lesser  grades  of  peripheral  neuritis  which  are 
generally  attended  by  paresthesia,  e.g.,  alcohol 
neuritis.  And  again,  pressure  on  the  radialis 
will  arouse  the  sleeper  with  a  painful  sensation. 
This  goes  away  so  long  as  he  keeps  awake  only 
to  return  again  with  the  next  nap. 

The  same  condition  may  be  observed  in  any 
kind  of  mechanical  lesion  of  the  nerve  trunk, 
or  in  secondary  neuritis  through  toxic  or  thermic 
influences. 

These  phenomena  are  of  importance  to  the 
internist  in  cases  of  tumor,  e.g.,  of  the  supra- 
clavicular  glands,  or  in  aneurysm  of  the  sub- 
clavian  aorta,  in  mediastinal  tumors,  in  diseases 
of  the  pulmonary  lobar  pleura  with  a  contracted 
apex  pleura  and  in  perineuritis ;  likewise  in 
paresthesia  of  the  upper  arms.  Their  presence 


274  GENERALIZED   PAIN 

here  may  mean  the  involvement  of  a  sternal  rib. 
At  other  times  they  are  merely  forerunners  of 
a  true  neuritis.  As  typical  symptoms  may  be 
considered:  increasing  painfulness,  local  tender- 
ness in  the  nerves  and  muscles,  sensibility  dis- 
orders, change  in  the  tendon  reflexes,  trophic 
disturbances,  muscular  paralysis,  change  in  the 
electric  reaction  and  demonstrable  thickening  of 
the  affected  nerve  trunks. 

I  wish  to  point  out  that  this  "forerunner  sta- 
dium" in  chronic  neuritis  may  endure  for  a 
considerable  space  of  time.  This  is,  for  instance, 
the  case  in  alcohol  neuritis,  which  is  also  attended 
with  vasoconstriction  in  the  fingers.  If  a  trau- 
matic condition  has  preceded  the  attack  of  neu- 
ritis, the  diagnosis  may  be  somewhat  involved, 
but  it  will  find  a  firm  hold  in  the  facts:  that  the 
manifestations  are  constant,  though  fluctuating 
in  intensity,  that  periodical  total  intermittence 
is  wanting,  that  they  are  confined  to  a  definite 
nervous  zone,  that  there  is  proof  of  local  sensi- 
tiveness in  the  aforesaid  limited  nervous  area, 
and  the  absence  of  hysterical  symptoms. 

Certain  cases  of  chronic  poisoning — carbon- 
oxysulphid  used  in  vulcanizing  india  -  rubber 
tubes — cause  true  toxic  neurosis.  Paresthesia 
of  the  extremities  is  an  essential  symptom. 
Other  signs  are  cyanosis  of  arms  and  legs,  tre- 
mor, giddiness,  loss  of  memory,  parosnia  and 
pareugesia,  dyspepsia,  gastric  troubles  and  con- 


EXTREMITIES  275 

stipation.  Most  of  these  cases  are  based  upon 
a  functional  as  well  as  an  anatomical  lesion  of 
the  peripheral  and  central  nervous  system. 

A  paresthesia  of  this  kind  may  be  a  constant 
solitary  symptom  of  a  limited  peripheral  neu- 
ritis or  of  a  multiple  cutaneous  neuritis.  Local 
sensitiveness  in  the  nervous  processes  and  in- 
creased painfulness  in  motation  should  indicate 
the  proper  course  for  the  diagnosis.  The  sensa- 
tion of  icy  cold,  icy  draughts,  numbness  in  the 
nervus  cutaneus  femoris  externus  should  re- 
mind us  of  paresthetic  mercdgia.  For  differen- 
tial diagnostic  purposes  it  is  of  value  to  remem- 
ber that  it  may  be,  etiologically  speaking,  the 
result  of  any  given  form  of  neuritis  (gout,  dia- 
betes, cold,  trauma,  chronic  lead  poisoning,  post- 
infections,  etc.),  or  it  may  be  in  part  the  mani- 
festation of  tabes  dorsalis,  or  may  also  originate 
from  flat  foot. 

Equally  important  is  the  fact  that  paresthesia 
in  the  inner  region  of  the  thigh  (down  to  the 
knee)  coupled  with  incarceration  signs  point  to 
an  existing  obturator  hernia. 

Intestinal  auto-intoacication  and  flatulent  dys- 
pepsia also  have  their  paresthesias,  such  as  creep- 
ing sensations  in  the  hands,  heaviness  in  the  legs, 
together  with  a  number  of  vasomotoric  manifes- 
tations. We  observe  flushing  of  the  face  and 
heat  in  the  neck,  dizziness,  headache,  psychic 
changes,  anguish,  irritability;  the  patient  is  dis- 


276  GENERALIZED   PAIN 

gusted  with  his  work  or  unable  to  perform  his 
task,  or  tired  of  life,  there  are  symptoms  of 
diaphragmatic  elevation,  of  palpitation  of  the 
heart  and  shortness  of  breath,  especially  during 
the  night  when  the  intestinal  gases  are  stagnat- 
ing. Insufficient  stools,  flatulency,  increase  of 
ethereal  sulphuric  acid  in  the  urine,  regulation 
of  the  bowels  and  checking  of  the  intestinal 
fermentation  by  the  proper  diet  are  important 
factors  which  require  close  attention.  A  very 
strong  formation  of  intestinal  gas,  of  course,  is 
chiefly  only  a  secondary  phenomenon  of  irregu- 
lar circulation  in  the  intestinal  blood  vessels, 
but  it  may  also  mean  sclerosis  of  the  intestinal 
arteries,  abdominal  plethora,  polycythemia,  the 
initial  stage  of  insufficiency  of  the  heart,  inade- 
quate diaphragmatic  rhythm  or  retarded  portal 
circulation.  All  these  points  are  worth  studying. 

Uremia  is  another  endogenous  intoxication  in 
which  we  have  occasion  to  observe  the  condition 
of  "dead  fingers  or  toes"  or  syncope  of  the 
hands.  It  may  exist  as  an  independent  disease 
or  may  be  the  partial  manifestation  of  uremic 
migraine.  I  shall  refer  again  to  Raynaud's  dis- 
ease later  on. 

Paresthesias  in  one  or  several  limbs  are  also 
known  as  signs  of  spinal  affections,  but  chiefly 
as  companions  of  painful  sensations.  We  find 
them  in  tabes  when  the  patient  complains  of 
formication  in  the  extremities,  especially  in  the 


EXTREMITIES  277 

ulnar  side  of  the  fingers  (they  feel  furry),  of  a 
peculiar,  indefinite  sensation  in  the  soles  of  the 
feet  as  if  he  were  walking  on  india  rubber  or 
on  cotton  batting,  the  feet  feel  as  if  they  were 
wrapped  around  with  fur,  he  is  not  sure  whether 
he  is  walking  on  a  carpet  or  on  a  wooden  or 
stone  floor.  The  hands  feel  as  if  they  were  in 
woolen  gloves.  When  we  find  such  symptoms 
it  behooves  us  to  look  for  further  signs  charac- 
teristic of  tabes  and  we  must  not  forget  that 
the  incipient  manifestations  of  a  tabes  superior 
are  to  be  found  in  the  upper  extremities  together 
with  patellar  reflexes,  whilst  the  usual  signs  in 
the  lower  limbs  are  totally  wanting.  I  mean  lan- 
cinating pains  and  ataxia.  In  these  cases  pupil- 
lary symptoms,  ataxia,  hypoatony  and  sensibility 
disorders  in  the  upper  extremities,  symptoms  in 
the  optic  and  cerebral  nerves  (trigeminus)  are 
not  unimportant,  but  I  lay  particular  stress  upon 
the  fact  that  these  paresthesias  occur  by  prefer- 
ence in  the  region  of  the  ulnaris,  and  that  anes- 
thesia of  the  triceps  tendon,  likewise  analgesia 
of  the  ulnar  nerve  at  the  elbow  frequently  attend. 

Some  tabetic  patients  complain  of  sudden 
painful  itching  with  goose-flesh  formation  in  the 
skin  of  the  extremities.  But  when  paresthesias 
appear  in  the  articular  region  we  must  look  upon 
them  as  the  advance  agents  of  a  coining  tabetic 
arthropathy. 

In    syringomyelia    similar    paresthesias    are 


278  GENERALIZED   PAIN 

observed  in  the  extremities  (and  the  trunk) 
attended  with  vasomotoric  disorders.  If  the 
patient  is  insensitive  to  heat  and  pain,  but  shows 
symptoms  of  degenerative  muscular  atrophy  in 
the  distal  ends  of  the  upper  extremities,  trophic 
disturbances,  intensified  tendon  reflex,  scoliosis 
and  bulbar  disorders,  the  diagnosis  should  be 
plain. 

Multiple  sclerosis  is  another  affection  of  the 
central  nervous  system  in  which  paresthesias  in 
the  arm  or  in  the  hand  alone  are  the  preceding 
initial  symptom  of  the  disease.  They  may  be 
associated  with  pains  but  exist  also  without  them. 
We  hear  of  numbness  and  formication  in  the 
limbs.  For  the  early  diagnosis  I  draw  attention 
to  impairment  of  the  sense  of  touch,  the  patient 
is  unable  to  judge  of  depth  or  position  of  things 
and  is  awkward,  clumsy  in  his  actions.  The 
differential  diagnosis  may  be  difficult  under  these 
circumstances,  but  if  we  reflect  on  the  absence 
of  subjective  as  well  as  objective  pain,  the  ques- 
tion of  neuritis  will  be  eliminated.  Moreover, 
the  stronger  tendon  reflex  in  the  lower  extremi- 
ties, the  want  of  muscular  atrophy  and  the  ab- 
sence of  reflexes  in  one  side  of  the  abdominal 
wall,  at  any  rate,  speak  decidedly  against 
neuritis. 

Another  alternative  is  cerebro-spinal  syplulis. 
But  this  question  can  easily  be  settled  by  the 
Wassermarm  reaction  and  by  the  cytologic  and 


EXTREMITIES  279 

chemical  analysis  of  the  cerebro-spinal  fluid. 
The  disturbance  of  the  stereognostic  sense  might 
turn  our  mind  also  to  a  cerebral  lesion  localized 
in  the  parietal  lobe,  the  more  so  as  the  patient 
frequently  complains  of  periodic  headache  and 
dizziness.  The  want  of  cerebral  pressure  cannot 
be  used  without  risk  against  a  local  expanding 
lesion  in  the  lobe.  A  safe  diagnosis  can  only  be 
based  on  the  general  course  of  the  disease,  the 
conspicuous  fluctuations  and  the  regression  of 
the  symptoms,  the  complete  disappearance  of 
the  brachial  symptoms  and  the  evidence  of  the 
classical  signs  of  multiple  sclerosis,  signs  which 
may  not  set  in  for  years  after  we  have  seen  the 
patient  for  the  first  time.  Analogous  pares- 
thesias  in  the  hand  or  in  the  fingers  frequently 
enough  are  observed  during  the  progress  of  the 
disease. 

In  arteriosclerosis  of  the  spinal  cord  with  the 
spinal  form  of  dysbasia  angiosclerotica  pares- 
thesias of  the  lower  extremities  are  likely  to 
occur.  (See  "Pains  in  the  Chest.") 

Pernicious  anemia  travels  in  company  with 
paresthesias  in  the  extremities  arising  from  spinal 
causes.  The  same  conditions  prevail  also  in 
other  forms  of  anemia  and  in  severe  cases  of 
cachexia  (carcinoma,  tuberculosis,  syphilis,  dia- 
betes mellitus,  alcoholism). 

Paresthesias  abound  in  all  diseases  of  the 
spinal  cord,  viz.,  myelitis,  syphilis,  tumors,  hem- 


280  GENERALIZED   PAIN 

orrhages,  in  all  expanding  diseases  of  the  colum- 
nar canal  (leucemic  infiltrations).  In  all  of 
them,  meningitis  included,  they  are  surpassed 
by  the  pains. 

As  prodromal  symptoms  they  figure  in  acute 
spinal  affections;  so  in  epidemic  cerebrospinal 
meningitis. 

They  play  a  subordinate  role  in  hydrophobia. 
If  we  are  dealing  with  the  mitigated  form  in 
persons  who  have  been  vaccinated  with  anti- 
rabietic  serum  we  shall  find  sudden  symptoms 
of  debility  and  paralysis  in  the  lower  extremities, 
bladder  and  rectal  disorders,  facial  paralysis  and 
salivation.  The  anamnesis  and  the  consideration 
of  the  prodromal  manifestations,  i.e.,  restless- 
ness, insomnia,  depression,  loss  of  appetite,  pains 
in  the  head,  sacrum  and  joints  should  lead  the 
way  to  a  proper  diagnosis. 

But  they  may  just  as  well  be  the  prodromal 
symptoms  of  true  rabies  when  they  appear  in 
the  part  of  the  body  which  has  been  bitten  by 
a  mad  animal.  In  this  respect  they  remind  one 
of  the  paresthesias  and  dragging  pains  which 
are  so  often  observed  in  the  form  of  a  tetanic 
aura  in  tetanus  in  the  affected  part  before  mus- 
cular contractions  and  convulsions  set  in.  They 
are  always  a  most  serious  warning  of  an  impend- 
ing outbreak  of  tetanus  when  a  tetanus  (wound) 
infection  is  suspected. 

From  what  has  been  said  in  the  foregoing  pages 


EXTREMITIES  281 

it  will  be  clear  that  paresthesias  of  the  extremi- 
ties may  be  due  to  different  causes  in  one  and 
the  same  disease.  If  in  the  legs  they  may  be 
provoked  by  the  encroachment  of  a  leucemic 
gland  upon  the  peripheral  nerve  trunks,  or  they 
may  be  due  to  pressure  of  a  leucemic  infiltration 
on  the  nerve  roots  in  the  intervertebral  foramina 
or  to  a  leucemic  infiltration  of  the  meninges.  In 
some  rare  cases  of  accompanying  pernicious 
anemia  we  may  have  to  decide  whether  the  spinal 
processes  do  not  in  an  analogous  manner  cause 
the  paresthesias. 

When  the  patient  complains  of  paresthesias 
in  one  only  or  in  both  extremities  of  the  same 
half  of  the  body  we  must  think  of  a  cerebral 
affection.  Diseases  of  the  brain  occupy  the  area 
of  the  trigeminal  nerve  which  is  the  original 
habitat  of  paresthesias.  I  mention  here  the  sen- 
sation of  numbness  in  one-half  of  the  face,  espe- 
cially about  the  angle  of  the  mouth  and  around 
the  nose;  the  feeling  as  if  that  part  of  the  face 
were  entangled  in  a  cobweb  when  the  patient  is 
suffering  from  an  intrapontine  disease  or  from 
a  basal  affection  of  the  posterior  cranial  fossa, 
or  from  a  cerebellar  tumor,  cerebral  tabes  or 
syringomyelia.  On  the  other  hand  we  must  not 
forget  that  paresthesias  also  occur  in  the  arm 
or  in  the  arm  and  leg  on  the  same  side  of  the 
body  either  independently  or  in  combination  with 
paresthesias  in  the  trigeminal  region  as  a  symp- 


282  GENERALIZED   PAIN 

torn  of  a  cortico-cerebral  lesion.  This  is  obvious, 
because  the  sensible  cortical  centers  lie  behind 
the  central  groove  in  the  posterior  central  con- 
volution, but  overlap  only  a  minimal  part  of 
the  motoric  region.  Moreover,  the  localization 
in  the  extremities  is  often  subject  to  definite 
laws.  For  instance,  in  tabes  or  in  affections  of 
the  cauda  the  favorite  place  is  in  the  region  of 
the  nervus  cutaneus  exterior. 

If  the  patient  complains  of  sudden  numbness 
in  the  arm,  or  hand,  or  in  the  arm  and  corre- 
sponding leg  and  in  the  same  side  of  the  face, 
but  lasting  only  a  short  time,  and  motoric  im- 
pairment is  not  noticeable  we  may  take  it  as  a 
symptom  of  cerebral  arteriosclerosis  with  insuffi- 
ciency of  the  hemicerebral  circulation.  This 
alone  is  capable  of  bringing  about  recurrent  par- 
esthesias  in  the  extremities,  which,  however,  may 
also  be  superinduced  by  multiple  minor  hemor- 
rhages in  the  brain  or  by  minimal  multiple 
softening  processes  (cerebrosclerosis).  The  co- 
existence of  these  with  sclerosis  of  the  cerebral 
arteries  can  only  be  confirmed  by  unremitting 
cerebral  morbid  manifestations.  It  follows  that 
paresthesias  in  the  extremities  are  a  possible, 
though  not  unequivocal  symptom  of  a  cerebral 
hemorrhage.  The  other  symptoms  of  cerebral 
arteriosclerosis  are  headache,  dizziness,  amnesia, 
psychic  changes  and  frequently  a  feeling  of  heat 
in  the  top  of  the  head. 


EXTREMITIES  283 

Thrombosis  or  embolism  in  a  branch  area  of 
the  anterior  arteries  of  the  brain  may  produce 
the  same  kind  of  manifestations.  The  topo- 
graphical diagnosis  offers  no  difficulties  if  the 
unilateral  character  of  the  sensible  disturbance 
caused  by  the  paresthesias  is  demonstrable.  This 
is  also  the  case  when  the  disturbance  is  confined 
to  one  extremity  only — generally  the  arm,  espe- 
cially when  the  fleeting  nature  of  the  manifesta- 
tion, its  recurrent  tendency,  the  advanced  age  of 
the  patient  and  the  presence  of  sclerotic  con- 
ditions in  other  arteries  as  well  are  observed. 
Often  enough  the  remaining  characteristic  signs 
of  cerebral  arteriosclerosis  have  already  preceded 
the  attack.  In  some  cases  even  precursors  of 
hemiparesthesia,  a  transient  hemiparesis  or  hemi- 
plegia  or  impediments  in  speech  may  have  been 
observed.  (The  temporal  intermittence  is  fre- 
quently reversed.) 

A  similar  situation  in  juvenile  individuals 
should  remind  us  of  syphilitic  cerebral  endar- 
teritis,  in  which  we  may  also  find  additional  signs 
of  weakness  in  the  affected  extremity.  Of  course, 
in  some  cases  the  transient  symptoms  are  entirely 
due  to  the  endarteritic  conditions  themselves  or 
to  thrombosis  of  a  branch  artery,  to  the  latter 
particularly  if  the  cerebral  disturbances  persist 
for  a  long  time. 

Essential  arterial  hypertension  is  another  cause. 
This  condition  may  prevail  for  a  number  of 


284  GENERALIZED   PAIN 

years  without  molesting  symptoms,  yet  there 
comes  the  time  when  the  patient  begins  to  com- 
plain of  flatulence,  dyspnea  after  meals,  indi- 
gestion, headache,  dizziness  and  nycturia;  we 
find  a  second  aorta  tonus,  cardiac  hypertrophy 
and  permanent  arterial  hypertension.  Recent 
observations  attribute  the  cause  to  a  limited  scle- 
rosis of  the  arteries  of  the  medulla  oblongata 
and  subsequent  irritation  of  the  vasomotoric 
center. 

A  tumor  of  the  brain  in  the  motoric  or  adja- 
cent region  may  produce  paresthesias  of  the 
extremities.  Sometimes  they  are  of  a  permanent 
character  and  combined  with  progressive  cere- 
bral hemiparesis  which  at  first  affects  only  one, 
but  later  on  both  of  the  unilateral  extremities, 
and  subsequent  convulsions.  But,  the  same  as 
in  sensible  epilepsy,  these  paresthesias  may  also 
come  on  in  the  form  of  regular  attacks  on  the 
affected  portion  or  cover  the  entire  body,  or  else 
in  combination  with  motoric  convulsive  condi- 
tions (Jackson's  epilepsy).  The  attacks  may 
also  alternate  with  attacks  of  cortical  epilepsy. 
This  applies  to  tumors  of  the  parietal  lobe  with 
like  force. 

Of  course,  the  diagnosis  cannot  be  evolved 
from  these  symptoms  alone.  We  must  look  for 
other  important  signs,  such  as  headache,  cerebral 
vomiting,  psychic  changes,  infiltration  of  the 


EXTREMITIES  285 

optic  nerve  and  other  local  motoric  and  sensible 
irritating  manifestations. 

In  tumors  of  the  central  ganglia,  especially 
of  the  optic  thalamus  paresthesias  appear  in  the 
contralateral  extremities.  The  diagnosis  of  a 
tumor  of  the  optic  thalamus  will  not  be  difficult 
to  make  if  we  bear  in  mind  the  characteristic 
symptoms,  which  are:  pain,  objective  sensibility 
disturbances  (hyperesthesia  and  anesthesia) ; 
signs  of  a  motoric  and  paralytic  character,  i.e., 
hemiplegia,  one-sided  convulsions  with  tremor 
and  position  involuntarily  assumed,  contralateral 
hemianopsia,  hemichorea,  hemiathetosis,  mimic 
facial  paralysis  and  cerebral  pressure.  Tumors 
of  the  pons  are  likewise  associated  with  pares- 
thesias. Alternating  hemiplegia  is  the  cardinal 
symptom  of  this  pontile  affection. 

A  tumor  localized  in  another  part  of  the  brain 
may  in  the  same  manner  affect  the  sensible  cen- 
ters and  produce  contralateral  paresthesias,  for 
instance  a  tumor  of  the  peduncle  of  the  brain, 
but  particularly  a  tumor  of  the  cerebellum. 

Paresthesia  of  the  extremities,  hyperesthesia, 
paralysis  of  individual  groups  of  muscles  and 
impaired  memory  frequently  survive  a  heatstroke 
for  a  considerable  time. 

There  are  other  regional  affections  of  the  brain 
in  which  paresthesias  of  the  extremities  also  but 
only  occasionally  occur.  I  have,  however,  in  the 
foregoing  section  paid  more  attention  to  those 


286  GENERALIZED   PAIN 

cerebral  diseases  in  which  paresthesias  appear 
rather  as  early  symptoms  or  at  any  rate  as 
momentary  guiding  manifestations  and  in  con- 
sequence are  of  special  significance  for  the  diag- 
nosis. But  there  are  also  further  morbid  pro- 
cesses of  the  brain  which  up  to  the  present  time 
have  not  yet  been  properly  localized,  I  mean 
hemichorea  and  hemiparalysis  agitans  (forms  of 
disease  which  are  unilateral  in  the  beginning, 
but  become  generalized  later  on).  In  these 
affections  paresthesias  coupled  with  pains  con- 
stitute often  enough  the  incipient  stages  but 
may  prevail  throughout  the  whole  course  of  the 
disease. 

But  if  the  attack  sets  in  on  both  sides  then 
the  accompanying  paresthesias  and  pains  in  the 
extremities  are  also  the  predominant  initial 
symptom  of  the  disease  (chorea,  paralysis  agi- 
tans). The  question  is  still  sub  judice  whether 
paralysis  agitans  is  not  a  disease  of  the  secretory 
glands  rather  than  an  affection  of  the  brain. 
But  we  know  with  certainty  that  various  diseases 
of  the  hematopoietic  glands  begin  and  progress 
with  paresthesias  and  pains  in  the  extremities, 
e.g.,  myasihenia,  the  nosology  of  which  is  like- 
wise not  yet  clearly  established,  also  Basedow's 
disease ~,  myxedema,  Addison's  disease,  acrome- 
galy  and  tetany. 

In  acromegcHy  nocturnal  pains  and  even  more 
severe  rheumatoidal  pains  as  well  as  vasomotoric 


EXTREMITIES  287 

disorders  are  significant  prodromal  symptoms. 
Unless  measurable  alterations  in  the  distal  parts 
of  the  extremities  are  discernable,  the  diagnosis 
may  be  somewhat  intricate.  However,  irregu- 
larities (cessation)  of  the  menstrual  flow,  or 
impotence  in  the  male,  genital  atrophy,  pres- 
sure symptoms  in  the  brain  (hypophysis  tumor!) 
bitemporal  contraction  of  the  face  (hemianopsia) 
might  prove  reliable  guides.  The  course  of  the 
disease  itself  ought  to  confirm  our  suspicions. 
The  X-ray  should  be  used  early  and  often. 

The  ovaries  are  another  source  of  paresthesias 
and  pains  in  the  climacteric  period  (pseudo- 
gout).  As  predominant  features  of  the  meno- 
pause may  be  mentioned:  a  feeling  of  cold  in 
and  blue  coloring  of  the  distal  parts,  heat  rushes, 
congestion  in  the  head,  profuse  sweating,  dizzi- 
ness, fainting  fits,  abnormal  nervousness,  tremor, 
palpitation  and  accelerated  action  of  the  heart, 
pains  in  the  small  of  the  back,  in  the  bones,  back- 
ache, neuralgias  in  the  trigeminus,  in  the  ischiatic 
and  intercostal  nerves  and  Heberden's  nodes. 
The  anamnesis  is  the  main  prop  of  a  correct 
diagnosis.  But  we  must  not  disregard  the  fact 
that  climacteric  disorders  may  put  in  an  appear- 
ance years  before  the  menstrual  flow  ceases  and 
also  for  a  long  time  afterwards.  There  exists 
a  very  strong  interrelationship  between  the  ova- 
ries and  the  motoric  centers,  proof  of  which  we 


288  GENERALIZED   PAIN 

see  in  the  manifestation  of  various  paresthesias 
during  the  menstrual  molimina. 

Paresthesias  in  osteomalacia — due  to  vasocon- 
striction — are  a  part  of  the  initial  symptoms. 

In  the  caisson  disease  the  paresthesias  consist 
at  first  of  formication  in  the  extremities  and 
very  annoying  itching  of  the  skin  to  be  followed 
by  severe  boring,  gnawing  and  lancinating  pains 
with  subsequent  weakness  in  and  paralysis  of 
the  legs.  The  pains,  no  doubt,  are  due  to  irri- 
tation of  the  spinal  roots  by  gaseous  vesicles  in 
the  spinal  fluid,  while  the  paresthesias  may  be 
attributed,  if  not  to  the  same  cause,  then  to  the 
presence  of  gas  in  the  cutaneous  capillaries. 

Very  stubborn  paresthesias  in  the  extremities, 
(the  finger  tips  and  soles  of  the  feet)  are  not 
unusual  during  the  convalescent  period  in  scarlet 
fever.  But  when  coupled  with  angiospasms  or 
with  vasodilation  they  point  to  chronic  malaria. 
(Cf.  "Malaria.") 

Chronic  ergotine  poisoning  deserves  mention 
here.  The  diagnosis  of  this  "creeping  sickness" 
is  based  on  the  symptoms  of  contraction  of  the 
flexor  muscles  in  the  toes,  wrists  and  fingers, 
and  of  the  extensor  muscles  of  the  big  toe,  knee 
and  elbow,  and,  if  tonic  cramps  of  the  muscular 
system  of  the  extremities  and  the  thorax  and 
manifestations  of  peripheral  gangrene  are  want- 
ing, then  on  the  creeping  sensation  and  the 
anamnesis.  When  the  microscope  shows  the 


EXTREMITIES  289 

presence  of  ergot  in  the  stools,  further  proof 
of  ergotism  is  hardly  required. 

Hemiparesthesia  and  hemialgesia  are  associ- 
ated with  chrome  nicotinism.  We  also  find  dif- 
fuse, dragging,  lancinating  pains  in  the  extrem- 
ities. Headache  (pressure),  dizziness,  mental 
sluggishness,  neurasthenia,  fainting  fits,  tremor, 
depression,  anguish,  cardiac  arythmia,  anginoid, 
even  anginose  conditions  and  visual  disturbances 
are  among  the  salient  features.  Of  course,  it  is 
self-evident  that  these  hemiparesthesias  have 
their  genesis  in  unilateral  spasms  of  the  cerebral 
arteries  (intermittent  limping!). 

Of  different  origin  are  the  paresthesias  in 
chronic  arsenic  poisoning.  They  are  the  first 
symbol  of  toxic  arsenical  neuritis  and  are  soon 
joined  by  severe  pains  in  the  lower  extremities, 
later  on  by  missing  reflexes.  As  classical  warn- 
ing signals  we  may  consider  the  existence  of 
certain  catarrhal  conditions  in  the  mucous  mem- 
branes (conjunctivitis,  rhinitis,  pharyngitis, 
bronchitis,  gastroenteritis,  colic  and  diarrhea) ; 
likewise  generalized  neurotic  states  (fatigue, 
headache,  giddiness,  sleeplessness),  cutaneous 
lesions  (erythema,  papules,  herpes,  furunculosis, 
brownish  coloration  of  the  skin)  and  fever. 
Laboratory  tests  of  the  excreta  (urine,  stools, 
vomitus)  furnish  additional  evidence. 

In  lead  poisoning,  paresthesias  are  of  minor 
importance;  but  there  are  exceptions,  because  in 


290  GENERALIZED   PAIN 

certain  cases  paresthesias  in  the  upper  extremi- 
ties spring  very  prominently  into  the  fore- 
ground. The  blue  line,  lead  colic,  arthralgia, 
paralysis  and  punctated  erythrocytes  should  as- 
sure a  positive  diagnosis. 

Paresthesias  in  the  most  diverse  areas  of  the 
skin  are  typical  of  pellagra.  We  find  them  in 
the  characteristic  erythema  itself,  but  also  in 
other  places,  such  as  the  arms,  shoulders  and 
epigastrium;  all  no  doubt  of  neuritic  origin. 

Paresthesias  in  the  upper  extremities,  espe- 
cially the  upper  left,  and  coupled  with  vaso- 
motoric  disorders,  form  an  essential  constituent 
of  angina  pectoris  vasomotoria.  But  they  are 
no  less  an  accompanying,  if  not  an  initial,  symp- 
tom of  true  coronary  arteriosclerosis.  This  item, 
however,  belongs  in  the  chapter  on  "Cardiac 
Pains." 

Similar  conditions  come  under  our  notice  in 
dyspragia  angiosclerotica  (intermittent).  Inso- 
far as  the  lower  extremities  are  concerned,  this 
disease  is  also  known  by  the  name  of  intermittent 
claudication,  or  intermittent  dysbasia.  Although 
paresthesias  and  vasoconstriction  usher  in  and 
accompany  the  attack,  yet  the  pain  is  the  pre- 
ponderating symptom. 

I  wish  to  emphasize  the  fact  that  in  some 
rare  cases  of  dysbasia  intermittens  angioscler- 
otica the  subjective  troubles  consist  chiefly  in 
the  paresthesias,  possibly  coupled  with  paleness 


EXTREMITIES  291 

and  low  temperature  in  the  affected  limb.  If 
this  happens  in  the  arm,  it  is  rather  significant, 
because  it  might  easily  lead  to  a  differential 
diagnosis  of  occupational  neurosis.  But  the  fact 
that  in  this  disease  the  paresthesias  attack  ex- 
clusively those  parts  of  the  anatomy  which  come 
into  immediate  action  by  the  exercise  of  the 
vocational  calling  (piano  players,  writers' 
cramps,  cigar  and  cigarette  makers)  should 
prevent  a  plausible  mistake.  The  more  so  as 
in  dysbasia  the  paresthesias  closely  follow  upon 
every  kind  of  muscular  overexertion.  Besides, 
here  we  also  find  arteriosclerosis  and  other  arte- 
rial constrictions. 

On  the  one  hand  we  know  that  dysbasia  (resp. 
dyspragia)  is  conditioned  by  an  anatomical 
morbid  process  of  the  arteries,  chiefly  sclerosis 
or  arteritis,  but  not  absolutely.  On  the  other 
hand,  we  are  also  aware  of  the  fact  that  every 
patient  who  complains  of  paresthesias  such  as 
described  above,  i.e.,  a  feeling  of  numbness  and 
cold  in  the  hands  and  feet,  is  the  possible  victim 
of  arteriosclerosis  or  endarteritis  obliterans  in 
the  affected  parts.  It  is  likewise  a  matter  of 
common  knowledge  that  endarteritic  or  scler- 
otic arteries  are  subject  to  vasomotoric  attacks 
on  the  ground  of  hyperirritation  of  their  own 
vasomotors  through  arteriosclerotic  or  arteritic 

processes. 

Again,  the  constriction  of  the  arteries  caused 


292  GENERALIZED   PAIN 

by  sclerosis  in  itself,  i.e.,  without  the  co-efficiency 
of  the  vasoconstrictors,  prepares  the  ground  for 
paresthesias.  This  explains  why  we  find  at  times 
paresthesias  in  the  ulnar  side  of  the  left  upper 
arm,  or  still  more  so  in  the  left  forearm  and  in 
the  left  hand,  sometimes  in  union  with  pains, 
hyperalgesia,  more  rarely  hyperesthesia,  in  the 
paresthetic  area  as  an  individual  sign  of  aortic 
sclerosis.  The  thought  also  lies  near  that  every 
form  of  restricted  circulation  in  the  extremities 
is  a  likely  cause  of  local  paresthesias.  For  in- 
stance, a  constriction  of  the  subclavian  artery 
due  to  exclusive  sclerosis  of  the  aortic  arc  (i.e., 
pure  aortic  sclerosis),  or  due  to  an  aneurysm 
of  the  anonyma,  a  distortion  of  the  subclavia  by 
a  mediastinal  induration  or  by  the  expansion 
of  a  mediastinal  tumor,  may  give  rise  to  pares- 
thesia  in  the  appurtenant  region,  if  only  in  the 
fourth  or  fifth  finger. 

The  diagnosis  is  not  hard  to  make,  especially 
in  the  face  of  diminished  pulse  beat  on  the 
constricted  side,  the  low  temperature  in  the 
affected  extremity,  the  subjective  feeling  of 
cold,  paleness,  marbling  or  cyanosis  of  the  skin, 
hyperesthesia,  change  in  the  tendon  reflexes, 
conspicuous  difference  in  the  blood  pressure 
between  right  and  left,  or  swelling  of  the 
extremity.  Constriction  of  the  abdominal  aorta 
superinduced  by  an  embolus  developing  in  its 
bifurcation  and  aggravated  by  a  secondary 


EXTREMITIES  293 

thrombosis  in  the  embolus  can  at  all  times  give 
rise  to  paresthesias  in  the  lower  extremities. 

But  not  only  a  constriction,  but  any  other 
kind  of  impairment  of  the  venous  circulation 
in  the  extremities,  will  give  rise  to  local  pares- 
thesias (varices,  thrombosis). 

Phlebectasia  is  affiliated  with  sensations  of 
creeping,  numbness  and  heat  in  the  extremities, 
especially  when  the  patient  has  been  on  his  feet 
for  a  long  time. 

In  thrombosis,  also,  there  is  a  feeling  of  cold, 
heaviness,  numbness  and  formication.  These 
may  be  even  the  first  perceptible  symptoms. 
In  chlorosis,  for  instance,  a  convalescent,  run 
down  by  a  long  spell  of  illness,  will  complain 
of  paresthesias  in  the  leg  caused  by  thrombosis 
of  the  deeper  muscular  veins.  When  these  alone 
are  thrombosed  and  no  superficial  veins  are 
involved,  the  diagnosis  is  not  always  so  easy  to 
make,  because  the  common  local  symptoms  of 
thrombosis,  the  formation  of  an  edema  in  the 
skin,  are  frequently  wanting,  and  the  throm- 
botic  cord  cannot  always  be  felt  by  the  palpat- 
ing finger.  Yet,  to  speak  from  my  own  experi- 
ence, the  cardinal  symptom  of  thrombosis  is 
always  sensitiveness  on  pressure  in  the  deeper 
muscles  (of  the  calf)  when  combined  with  par- 
esthesia  and  a  slight  swelling  of  the  glands,  at 
any  rate  in  diseases  which  tend  to  marantic 


294  GENERALIZED   PAIN 

thrombosis,  e.g.,  insufficiency  of  the  cardiac 
muscle,  blood  diseases,  cachexia,  etc. 

Paresthesias  in  the  extremities  are  not  only  a 
possible  sign  of  an  existing  thrombosis,  but  they 
are  also  apt  to  precede  the  disease,  and  thus 
constitute  a  premonitory  symptom.  Of  course, 
numbness,  an  enfeebled  constitution  and  heavi- 
ness in  the  extremity  are  not  always  deciding 
factors.  I  lay  more  stress  upon  subfebrile  tem- 
perature, and  above  all  on  the  finding  of  a 
climbing  pulse,  although  some  authors  deny  the 
significance  of  the  latter. 

It  is  not  unimportant  for  the  diagnostician 
to  remember  that  ever  recurring  paresthesias  in 
one  limb  may  have  their  genesis  also  in  other 
mechanical  disorders  of  the  vascular  system.  I 
have  seen  female  patients  who  complained  about 
creeping,  cold  or  heat  in  one  or  both  lower  ex- 
tremities, without  any  apparent  cause  for  the 
trouble.  I  recommended  not  to  lace  the  foot- 
wear so  tight  and  use  more  elastic  garters. 
Relief  came  promptly.  Close-fitting  boots  and 
crossing  the  knees  are  other  causes  of  these 
tribulations.  But  it  is  not  only  congested  cir- 
culation, but  also  the  effect  on  the  peripheral 
and  vascular  nerves,  and,  not  any  the  less,  cold 
dampness  which  produce  these  anesthesias  and 
painful  sensations. 

In  hysteria,  the  vasoconstricting  manifesta- 
tions are  generally  wanting  and  the  paresthesias 


EXTREMITIES  295 

are  less  characteristic,  but  instead  we  have 
strongly  marked  sensibility  disorders  and  other 
hysterical  stigmata,  all  of  which  are  typically 
different  from  genuine  acroparesthesias. 

In  neurasthenia,  spontaneous  paresthesias  are 
relatively  uncommon,  excepting  sexual  neuras- 
thenia with  its  sensations  of  cold  in  the  ex- 
tremities. But  when  they  do  occur  a  differen- 
tiation from  genuine  neurosis  can  be  made  from 
the  general  clinical  picture,  from  the  other 
neurasthenic  symptoms,  and  also  from  the  sex 
of  the  patient  (neurasthenia  prevails  in  men, 
acroparesthesia  in  women).  Moreover,  in  neu- 
rasthenia, paresthesia  is  not  spontaneous,  but 
rather  due  to  some  minor  lesion  of  the  nerves, 
the  sensation  persists  after  the  nerve  trunk  has 
been  pressed  for  a  short  time,  or  it  comes  on 
when  one  foot  is  resting  on  the  other  or  the 
leg  is  a  bit  tired  out. 

Cold  hands  and  feet  are  often  the  reflex  ac- 
tion of  vasomotoric  neurosis  due  to  adynema. 
Lank,  lean  young  persons,  with  a  glaring  stare 
or  a  floating  rib,  who  suffer  from  enteroptosis 
or  orthotic  albuminuria,  etc.,  are  good  subjects 
for  this  form  of  neurosis. 

That  complains  of  cold  feet  or  hands  caused 
by  any  other  form  of  impaired  circulation,  such 
as  arteritis,  arteriosclerosis,  phlebectasy,  phlebo- 
sclerosis,  partial  thrombosis  of  the  veins,  weak- 
ness or  paralysis  of  the  vascular  nerves  (peri- 


296  GENERALIZED   PAIN 

pheral  or  central),  is  an  important  sign  of 
myxedema  resp.  hypothyreosis  due  to  excessive 
use  of  coffee  or  tea,  is  only  mentioned. 

Raynaud's  disease  is  another  deuteropathic 
acroparesthesia  which  is  of  special  interest  to 
the  diagnostician.  The  patient  complains  of 
cold,  paleness  or  else  livid  coloration  of  the 
fingers  or  toes  (dead  fingers,  dead  toes).  Such 
an  "isolated"  acroparesthesia  (digitus  semimor- 
tuus)  has  a  double  bearing:  (1)  It  is  fre- 
quently an  accompanying,  if  not  an  initial,  sign 
of  true  angina  pectoris;  (2)  it  is  also  a  common, 
if  not  the  most  essential,  sign  of  uremic  intoxi- 
cation. Albuminuria,  cylindruria,  hematuria 
(all  of  these  may  be  missing  for  a  long  time 
in  contracted  kidney),  reduction  in  the  urinary 
output,  low  specific  quantity  and  light  coloring 
of  the  urine,  nycturia,  pollakisuria,  strong  sec- 
ond aorta  tonus,  high  blood  pressure,  increased 
tendon  reflex,  dyspepsia,  uremia,  very  dry,  car- 
dio-renal-edematous  skin,  changes  in  the  fundus 
of  the  eye  (retinitis,  hemorrhage),  congested 
secretion  (chlorine,  iodide,  sugar  of  milk)  in  the 
kidneys,  increased  retention  of  nitrogen,  indi- 
canuria,  Ambard's  coefficient  and  abnormal  con- 
tent of  urea  in  the  cerebrospinal  fluid,  are  suffi- 
cient indications  for  a  correct  diagnosis. 

Chlorosis  is  often  distinguished  by  this  mani- 
festation of  dead  fingers  with  severe  pains  dur- 
ing regular  intervals.  The  diagnosis  should  be 


EXTREMITIES  297 

obvious  because  this  disease  is  almost  exclusively 
confined  to  young  women.  The  peculiar  look 
and  appearance  of  the  patient,  menstrual  disor- 
ders, the  condition  of  the  blood,  the  absence  of 
other  anemic  signs,  the  effect  of  iron  and  arsenic 
treatment,  are  other  points  of  interest. 

Some  cases  of  arteriosclerosis,  myocarditis  and 
nephrosclerosis  are  on  record  in  which  acro- 
paresthesia  was  restricted  to  one  finger. 

II.  Pains  in  the  Bloodvessels 

When  vascular  lesions  are  the  source  of  pain, 
the  first  disease  to  think  of  is  angina  pectoris, 
with  its  irradiations  into  the  left,  rarely  in  both, 
and  very  seldom  in  the  right  arm  alone,  espe- 
cially on  the  side  of  the  little  finger,  and  also 
on  account  of  its  initial  and  concomitant  vaso- 
constricting  symptoms.  For  particulars  I  refer 
the  reader  to  the  chapter  on  "Cardiac  Pains." 

I  will  touch,  however,  on  a  few  facts  which 
really  appertain  to  this  section.  First  of  all, 
it  is  by  no  means  impossible  for  these  typical 
irradiations  to  reach  out  into  the  lower  extrem- 
ities or  loins,  or  even  the  testicles.  Secondly, 
painful  attacks  in  the  upper,  or  also  in  the 
lower,  extremities  are  liable  to  represent  the 
initial  symptom  of  angina  pectoris;  in  fact, 
manifest,  recurrent  pains  in  the  left  arm,  or 
perhaps  only  in  the  left  forearm,  may  very  well 
be  the  solitary  symptom  of  this  disease.  I  will 


298  GENERALIZED   PAIN 

go  even  further  and  claim  that  pains  in  the  left 
wrist,  sometimes  encircling  it  like  a  tight  brace- 
let, at  other  times  settling  only  in  the  palmar 
side,  are  a  grave  warning — especially  when  com- 
bined with  a  terrible  feeling  of  agony — of  a  fatal 
anginose  attack. 

In  all  these  cases  of  peripheral  angina  pec- 
toris,  it  seems  to  me  that  the  pain  is  centered 
in  the  nerves  of  the  bloodvessels,  if  not  entirely, 
then  in  part  for  certain,  whence  it  radiates  into 
the  neighboring  nervous  fields.  The  diagnosis 
cannot  go  wrong  when  we  observe  a  simulta- 
neous and  continued  extension  of  the  pains  in 
the  chest  accompanied  by  anguish  and  the  other 
signs  of  stenocardia.  Analogous  irradiations  of 
pain  in  the  arm  are  observable  also  in  anginoid 
conditions,  companions  of  acute  or  chronic  myo- 
carditis or  pericarditis. 

Arterial  constriction  in  the  extremities  is  a 
very  ordinary  cause  of  painful  sensations  in  the 
legs.  I  aim  here  at  dyspragia  resp.  dysbasia 
inter  mittens,  intermittent  claudication,  no  matter 
whether  caused  by  arteriosclerosis  or  endarteritis 
obliterans  or  syphilitic  endarteritis  with  or  with- 
out vasoconstriction,  or  even  provoked  by  the 
latter  alone.  I  have  already  spoken  at  length 
about  this  affection  in  a  previous  section  and,  to 
avoid  repetition,  I  refer  the  patient  reader  to 
that  part  of  my  book. 

The  painful  attacks  connected  with  this  dis- 


EXTREMITIES  299 

ease  are  obviously  due  to  overtaxation  of  the 
peripheral  vessels.  We  can  find  the  evidence  in 
the  absence  of  arterial  pulsation  without  claudi- 
cation,  in  the  missing  pulse  during  the  attack; 
or  else,  in  the  typical  claudication  of  the  remain- 
ing pulsation;  and  again,  in  claudication  based 
on  vasoconstriction  alone  (in  anemia,  neurosis, 
nicotinism),  and  finally  in  unilateral  claudication 
when  the  trunk  of  the  crural  artery  is  sclerosed 
on  both  sides  and  the  arterial  pulse  is  missing 
in  the  smaller  branches.  This  bronchial  defect 
will  be  found  on  that  side  in  which  an  old  peri- 
colitic  (post-dysenteric)  exudate  pinches  the 
ischiadic  nerve  (thus  producing  a  onesided 
ischias)  and  hyperexcites  the  vascular  nerves  by 
this  constriction. 

Similar  conditions  may  arise  from  sclerosis 
of  the  trunk  of  the  crural  or  iliacal  arteries  or 
any  other  local  constriction  or  acute  arteritis. 
It  is  hardly  necessary  to  add  that  dysbasia  is 
often  followed  by  gangrene.  In  chronic  nico- 
tinism intermittent  dysbasia  may  be  caused  by 
periodic  or  continuous  angiospasm  when  the 
arterial  walls  remain  quite  normal  (the  X-ray 
gives  the  required  information).  The  pulses  are 
modified  during  the  attack  but  never  entirely 
missing. 

Chronic  lead  poisoning,  ergotism,  neurasthenia, 
chlorosis  and  juvenile  anemia  must  be  rubri- 
cated here  also.  In  addition  be  it  said  that  a 


300  GENERALIZED   PAIN 

combination  of  several  different  etiological  fac- 
tors may  produce  a  focus  from  which  dysbasia 
is  set  in  motion.  Is  it  necessary  to  say  that  there 
is  a  form  of  neuritis  which  takes  its  genesis  from 
arteriosclerosis  and  that  in  consequence  neuritic 
manifestations  are  also  observed  in  dysbasia? 
But  this  does  not  justify  us  to  apply  the  term 
"neuritic  dysbasia"  to  a  form  of  dysbasia  which 
is  conditioned  by  neuritis. 

As  changes  in  the  arterial,  so  may  anomalies 
in  the  venous  passage  ways  of  the  blood  give 
rise  to  intermittent  dysbasia,  in  fact  the  more  so 
when  the  arteries  have  already  been  attacked. 
Phlebectasy  and  phlebosclerosis  are  the  chief 
offenders.  The  diagnosis  is  facilitated  by  the 
ectatic  state  of  the  veins  of  the  skin  which  is 
plainly  visible.  In  women  who  have  offspring 
or  are  with  child,  in  persons  who  are  forced  to 
stand  most  of  the  time,  or  in  very  corpulent 
individuals  the  veins  are  not  always  very  visible. 
In  such  cases  the  bloodvessels  can  be  made  prom- 
inent if  the  patient  is  asked  to  let  the  lower  limbs 
hang  down  loosely  for  a  while.  In  some  cases 
of  phlebectasia  the  trunks  of  the  veins  are  not 
perceptibly  enlarged,  but  we  shall  always  be  able 
to  find  a  bluish  network  of  the  smaller  vessels 
on  the  bridge  of  the  foot  or  else  on  the  inner 
surface  of  the  thigh.  When  the  muscular  veins 
are  very  strongly  varicosed  while  the  cutaneous 
vessels  show  only  slight  traces  of  ectasy  we  may 


EXTREMITIES  301 

with  safety  ascribe  an  existing  dysbasia  to  that 
condition.  Errors  in  the  diagnosis  can  always 
be  avoided  by  a  careful  clinical  examination. 
Nevertheless,  for  safety's  sake,  I  will  add  a  few 
hints. 

It  will  happen  that  ischias  is  diagnosed  when 
it  is  really  a  case  of  dysbasia  and  not  without 
reason.  There  are  cases  of  ischias  in  which  the 
pain  is  very  much  aggravated  by  walking.  But 
we  may  be  safeguarded  when  we  take  into  con- 
sideration that  the  ischiatic  pain  is  constant, 
perhaps  only  in  a  milder  form,  when  the  leg  is 
at  rest.  Moreover,  we  have  the  typical  localiza- 
tion of  the  pain  in  the  region  of  the  ischiadic 
nerve,  local  sensitiveness  there,  sharpening  of  the 
pain  when  the  abdominal  press  comes  into  action 
(during  coughing,  defecating),  tenderness  in  the 
lower  lumbar  vertebrae,  Lasegue's  sign,  change 
in  the  Achilles  tendon  reflex,  lower  temperature 
in  the  patellar  skin  of  the  affected  part.  The 
diagnosis  of  radicular  ischias  will  be  discussed 
later  on. 

Peripheral  neuritis  is  another  stumbling  block, 
because  here  also  the  pains  are  exacerbated  by 
walking,  the  affected  muscles  are  stiffened  and 
indurated.  But  the  diagnosis  can  be  made  from 
the  typical  signs  of  neuritis,  eventually  pseudo- 
tabes  (sensitiveness  of  the  nerve  trunks  and 
muscles,  muscular  atrophy,  trophic  disorders, 


302  GENERALIZED   PAIN 

motoric  inhibitions,  ataxia,  changes  in  the  tendon 
reflexes,  reaction  to  the  electric  current). 

Another  source  of  error  consists  in  a  subor- 
dinate form  of  neuritis  in  the  legs,  i.e.,  arterio- 
sclerotic  neuritis  which  rests  on  the  same  basis 
as  dysbasia,  i.e.,  sclerosis  of  the  arteries.  The 
pains,  noticed  at  first  during  walking,  later  on 
also  when  at  rest,  are  localized  either  in  the 
crural  or  ischiadic  zone,  or  in  both  together. 

Sensibility  disturbances  and  tenderness  in  the 
nerve  trunks  are  hardly  ever  present.  But  a 
differentiation  is  rendered  possible  by  the  decline 
of  the  tendon  reflexes,  the  presence  of  muscular 
paresis  and  atrophy,  and  also  by  the  existence  of 
the  arterial  pulse  in  arteriosclerotic  neuritis.  In 
complications  between  the  two  diseases  the  ten- 
don reflexes  and  the  arterial  pulse  in  the  foot 
are  wanting. 

Another  important  point  is  that  both  neuritis 
and  arteriosclerotic  dysbasia  may  have  a  parallel 
existence,  independent  of  arteriosclerosis  as  a 
causative  element. 

I  know  full  well  that  despite  this  apparent 
parallelism,  dysbasia  can  only  exist  as  a  uni- 
lateral disease.  Still  my  contention  is  that  wher- 
ever the  nerves  of  the  extremities  are  most 
vulnerable,  there  and  in  that  place  intermittent 
claudication  may  also  take  its  exclusive  abode. 
Also,  insofar  as  the  development  of  dysbasia  is 
concerned,  we  must  reckon  with  two  factors, 


EXTREMITIES  303 

i.e.,  stability  of  the  vascular  affection  and  the 
transitory  element  of  the  nervous  system,  espe- 
cially of  the  vasomotors. 

Acinesia  algera  causes  pains  in  the  arms  or 
legs.  It  is  easily  recognized  and  distinguished 
from  dysbasia  by  the  fact  that  the  pains  set  in 
at  once  when  the  patient  even  attempts  the 
slightest  movement,  in  consequence  he  remains 
motionless.  There  are  no  morbid  changes  in  the 
bloodvessels.  The  pains  are  felt  with  the  same 
intensity  in  other  parts  of  the  body,  chiefly  in 
the  back  and  in  the  head.  We  also  find  gen- 
eralized neurotic  symptoms  of  hysteria,  neuras- 
thenia or  psychosis. 

Neurasthenia  is  sometimes  a  regular  counter- 
feit of  intermittent  dysbasia.  The  patient  does 
complain  of  rather  moderate  pains  after  a  long 
walk,  but  soon  finds  rest  again.  We  shall  not 
go  astray  if  we  keep  a  careful  eye  on  the  fol- 
lowing points:  no  changes  in  the  bloodvessels, 
no  trace  of  other  causal  movements,  but  presence 
of  other  neurasthenic  signs,  the  youthfulness  of 
the  patient  (generally  male),  proof  of  preceding 
psychic  emotion  and  overexertion.  The  prog- 
nosis is  favorable. 

In  meralgia  paresthetica  the  pains  come  on 
with  walking,  at  first  the  exercise  modifies  but 
later  on  aggravates  them  and  they  disappear 
only  when  the  patient  comes  to  rest.  The  pain- 
fulness,  however,  is  clearly  confined  to  the  region 


304  GENERALIZED   PAIN 

of   the    nervus    cutan.    femoris    externus    with 
hypesthesia  or  anesthesia  of  the  skin. 

Flat  foot  accounts  for  another  error  in  the 
diagnosis  of  dysbasia.  It  is  one  of  the  common- 
est causes  of  pain  in  the  lower  extremities  and 
for  that  very  reason  so  often  misunderstood, 
simply  because  the  patient  very  rarely  complains 
of  pain  in  the  foot.  He  rather  speaks  of  a  pain- 
ful tension  in  the  calves  or  knees,  of  paresthesia 
in  the  outer  side  of  the  thigh  (meralgia),  or  in 
the  hips,  so  that  an  erroneous  diagnosis  of  ischias, 
or  of  a  painful  affection  of  the  knee — or  hip 
joint  easily  slips  in.  And  yet  the  diagnosis  is 
plain  and  simple  enough,  if  we  only  bear  in 
mind  that  not  every  patient  who  comes  to  us 
for  advice  must  of  necessity  be  the  carrier  of 
an  internal  disease.  In  a  way  flat  foot  resembles 
dysbasia,  that  is  to  say,  the  patient  complains 
in  both  of  pains  in  the  leg,  i.e.,  in  the  calves,  in 
the  nates  and  in  the  loins,  pains  which  are  awak- 
ened by  walking  but  disappear  during  the  resting 
time.  If  they  are  mitigated  or  even  vanish 
during  a  longer  walk  we  have  evidence  against 
dysbasia.  We  know  very  well  that  flat  foot 
patients  suffer  from  severe  pains  when  they  have 
been  standing  on  their  feet  all  day  long.  In 
the  morning  no  pain  is  felt  but  it  comes  on  and 
increases  in  intensity  as  the  hours  go  by.  This 
is  not  the  case  in  dysbasia.  Here  the  pains 
cease  so  soon  as  the  extremity  is  put  out  of 


EXTREMITIES  305 

action.  Moreover,  there  are  definite  external 
signs  by  which  a  pes  planus  can  be  recognized, 
the  instep  appears  inflected,  the  inner  condyle 
is  prominent,  a  vertical  line  drawn  from  the 
middle  of  the  popliteal  space  through  the  achilles 
tendon  deflects  outwardly  instead  of  hitting  the 
median  line  of  the  heel.  The  patient  walks  on 
the  outer  border  of  the  foot  and  wears  out  the 
heels  of  his  shoes  on  the  outer  side.  Flat  feet 
are,  as  a  rule,  abnormal  in  length.  Hallux  val- 
gus  of  the  big  toe  and  corns  on  the  little  toes 
are  other  characteristics  worthy  of  notice,  and 
so  are  pains  in  the  foot  itself  or  when  following 
passive  supination  of  the  foot  in  which  case  they 
generally  radiate  in  the  knee  and  hip  joints  and 
even  into  the  small  of  the  back  as  an  expression 
of  static  arthritis. 

A  common  sequel  of  flat  foot  is  venous  ectasy 
further  complicated  by  subsequent  dysbasia.  We 
must  bear  this  in  mind  when  a  patient  afflicted 
with  perceptible  ectatic  veins  complains  of  pains 
in  the  legs,  especially  for  the  reason  that  the 
self-same  causes  may  also  originate  phebectasy, 
e.g.,  preceding  pregnancy.  Of  more  common 
occurrence  still  is  intermittent  arteriosclerotic 
dysbasia  combined  with  flat  foot.  We  shall 
recognize  it  when  the  arterial  pulse  in  the  foot 
is  wanting. 

Of  course,  it  is  understood  that  all  forms  of 
talipes  cause  pains  in  the  feet  and  legs.  They 


306  GENERALIZED   PAIN 

belong  really  in  the  province  of  the  orthopedic 
surgeon. 

Achillodynia  is  a  symptom  complex  which 
forces  the  patient  to  complain  of  intensive  pains 
in  the  process  of  the  achilles  tendon  when  the 
feet  and  legs  are  in  motion.  We  generally  can 
find  a  small  local  tumor  about  as  hard  as  the 
tendon  itself.  It  is  due  to  some  slight  injury, 
a  pinching  shoe,  periostitis  or  tendovaginitis  and 
of  interest  to  the  internist  for  the  reason  that 
it  may  also  be  the  effect  of  gout,  gonorrhea, 
malaria  or  even  syphilis.  A  purely  psycho- 
genous  hysterical  form  of  achillodynia  seems  also 
to  exist. 

A  long  forced  march  or  some  other  unusual 
overexertion  of  the  lower  extremities  is  fre- 
quently followed  by  an  attack  of  very  painful 
dysbasia.  The  patient  can  walk  no  further  on 
account  of  muscular  cramps  in  the  calves,  or  in 
severer  cases  owing  to  a  traumatic  rupture  of 
some  muscular  fascia.  The  diagnosis  is  simple 
and  plain  enough. 

Myotonia  is  a  muscular  affection  which  owes 
its  origin  to  some  primary  disease  of  the  nervous 
system.  Its  special  symptom  is  a  painless  rigid- 
ity of  the  muscles  following  prolonged  physical 
exercise  especially  when  the  patient  has  been 
inactive  for  a  considerable  space  of  time  previous 
to  the  overexertion.  Yet  there  are  cases  in 
which  painful  tension  in  the  thighs  and  calves 


EXTREMITIES  307 

is  caused  by  walking.  The  pressure  of  hyper- 
tonus  in  an  otherwise  well  developed  muscular 
system,  the  fact  that  the  symptoms  disappear 
in  continued  exercise,  the  absence  of  vascular 
signs,  and  Erb's  myotonic  reaction  facilitate  the 
proper  diagnosis. 

Resembling  myotonia  and  for  that  reason 
often  mistaken  for  dysbasia  are  certain  rare 
cases  of  trichinosis  when  the  patient  complains 
of  cramps  and  stiffness  in  both  calves,  which 
makes  walking  difficult  but  disappear  again  with 
rest. 

There  are  also  sporadic  cases  of  osteomalacia 
in  which  intermittent  limping  is  caused  by  vaso- 
constricting  cramps  in  the  vessels.  The  charac- 
teristic symptoms  (see  chapter  on  "Pains  in  the 
Bones")  suffice  for  the  diagnosis. 

At  first  sight  we  may  gain  the  impression  of 
dysbasia  in  certain  cases  of  arteriosclerosis.  The 
patient  complains  of  pains  in  the  legs  which, 
however,  are  not  at  all  due  to  the  sclerotic  condi- 
tion but  to  an  entirely  different  cause.  I  remem- 
ber such  a  case.  The  patient  complained  of 
pains  every  time  he  made  an  attempt  to  walk 
and  showed  all  the  characteristic  symptoms  of 
arteriosclerosis.  But  the  fact  that  he  felt  pain 
in  the  legs  when  he  turned  around  in  bed  and 
that  constant  severe  pains  were  present  in  the 
sacrum  turned  my  attention  to  the  retroperi- 


308  GENERALIZED   PAIN 

toneal  space.  Upon  closer  examination  I  found 
a  carcinoma  in  the  pancreas  with  fatal  result. 

Dysbasia  or  rather  dyspragia  in  the  upper 
extremity  must  be  suspected  when  the  patient 
complains  of  pain  provoked  by  movements  of 
the  arm.  The  cause  for  this  congestion  in  the 
circulation  may  be  either  sclerosis  of  the  arteries 
and  their  branches,  or  a  sclerotic  constriction  of 
the  subclavian  artery  with  abnormal  vasomotoric 
irritation,  or,  less  frequently  simple  vasoconstric- 
tion. 

The  differential  diagnosis  between  dyspragia 
and  occupational  cramps  can  be  made  from  the 
fact  that  in  the  latter  no  anatomical  changes  in 
the  walls  or  in  the  lumen  of  the  vessels  are 
perceptible,  that  there  is  no  difference  in  the 
blood  pressure  on  the  affected  and  healthy  side, 
and  also  from  the  quality  of  the  pulsation,  all 
of  which  are  characteristic  symptoms  of  dys- 
pragia, where  the  arterial  pulse  may  be  even 
entirely  wanting  in  the  affected  side.  Further- 
more, in  dyspragia  the  pains  come  on  with  any 
kind  of  physical  activity,  e.g.,  during  meal  time 
or  when  combing  the  hair  and  not  rarely  with  a 
definite  occupation,  e.g.,  writing  or  playing  on 
a  musical  instrument.  Again,  dyspragia  mani- 
fests itself  sometimes  only  when  the  patient  is 
walking  attended  with  paresthesia,  paleness  and 
cold  in  the  affected  part.  All  this  is  due  to 
sclerosis  or  dilatation  of  the  appurtenant  aorta, 


EXTREMITIES  309 

or  to  pressure  of  a  cervical  rib  on  the  under- 
lying cervical  plexus  and  on  the  subclavian 
artery.  Here,  too,  paresthesia  may  manifest  it- 
self shortly  after  motation  of  the  arm.  Stitches, 
cold  or  hot  feeling  in  the  skin,  motoric  weakness 
amounting  to  a  quasi  paralysis  incommode  the 
patient  to  such  an  extent  that  an  object  he  holds 
in  the  hand  falls  to  the  ground. 

Diseases  of  the  vascular  system  give  also  rise 
to  other  varieties  of  pain  in  the  extremities. 

First  of  all  I  mention  here  that  sclerotic  arte- 
ries give  rise  to  moderately  painful  sensations 
along  their  whole  length  or  wall  by  way  of  the 
vascular  nerves.  Perhaps  we  find  the  artery 
sensitive  on  pressure,  i.e.,  when  we  squeeze  and 
roll  it  between  the  fingers.  We  may  also  detect 
changes  in  the  arterial  wall  when  we  palpate 
it  with  the  finger  nails.  This  is  a  valuable  hint 
which  I  have  tried  out  on  my  own  arteries. 

Long  continued  pains  in  one  or  both  lower 
extremities  combined  with  intermittent  limping 
is  the  natural  sequel  of  arteriosclerosis  with 
secondary  vascular  cramps  superinduced  by  ex- 
cessive smoking  or  a  psychic  shock  or  some 
physical  overexertion. 

Arteriosclerosis  of  the  extremities — the  same 
as  endarteritis — in  younger  persons  is  the  causa- 
tive factor  of  local  pains,  especially  in  the  distal 
parts  of  the  extremities  owing  to  defects  in  the 
circulation.  I  have  already  pointed  out  that 


310  GENERALIZED   PAIN 

paresthesia,  pain,  coldness  in  these  distal  parts, 
marbled,  livid,  pale  skin,  smallness  of  the  peri- 
pheral pulse  are  the  ruling  symptoms  for  the 
diagnosis  of  such  arterial  affections  possibly  fol- 
lowed by  subsequent  gangrene.  Arteriosclerotic 
neuritis  and  radiculitis  are  other  means  by  which 
arteriosclerosis  is  able  to  provoke  very  intensive 
pains  in  the  extremities.  These  pains,  at  times 
intermittent,  may,  in  fact,  constitute  the  one 
solitary  symptom  of  the  disease,  because,  as  a 
rule,  tenderness  of  the  nerves  and  muscles  and 
other  objective  sensibility  disturbances  are  com- 
pletely missing.  The  differentiation  from  arte- 
riosclerotic  dysbasia  rests  on  the  finding  of  the 
arterial  pulse. 

Arteriosclerosis  of  the  extremities  (arteritis 
obliterans)  and  Raynaud's  disease  are  the  origi- 
nators of  the  highest  degree  of  pains  in  the 
extremities  (the  distal  parts)  when  they  culmin- 
ate in  gangrene.  It  follows  that,  when  we  are 
confronted  by  gangrenous  conditions,  we  will 
have  to  decide  to  which  of  these  two  diseases  the 
present  state  is  due.  If  due  to  arteriosclerosis 
the  pains  have  preceded  the  attack  by  several 
weeks,  if  Raynaud's  disease  is  the  cause  they 
have  existed  for  several  years.  In  Raynaud's 
disease,  moreover,  the  gangrene  is  exquisitely 
symmetrical  and  synchronous  in  both  extremities 
and  remains  confined  to  the  same  locality,  whilst 
in  arteriosclerosis  it  is  of  a  progressive  nature 


EXTREMITIES  311 

with  total  loss  of  pulsation.  And  yet  there  are 
cases  in  which  these  points  do  not  afford  a  con- 
vincing differential  proof,  when  even  the  Roent- 
gen picture  fails  to  come  to  our  assistance.  This 
will  happen,  for  instance,  when  Raynaud's  dis- 
ease— likewise  erythromelalgia — runs  a  parallel 
course  with  arteriosclerosis. 

Very  sudden  pain  in  one  of  the  extremities 
may  at  any  time  be  ascribed  to  some  disease  of 
the  arteries.  Acute,  toxic,  infectious  arteritis 
obliterans  ranks  first  in  this  connection  with 
some  rare  cases  of  severe  acute  infections  (ty- 
phoid, influenza).  In  its  secondary  stage  it  is 
apt  to  give  rise  to  thrombosis  of  the  arterial 
trunk.  The  manifestations  of  arterial  ischemia, 
i.e.,  the  absence  of  pulsation,  pallor  and  coldness, 
hyparthesia  and  anesthesia  of  the  extremities  are 
sufficient  guides  for  the  diagnosis.  According 
to  recent  observations  a  severe  cold  in  the  form 
of  acute  rheumatic  arteritis  is  a  likely  factor 
when  it  has  directly  preceded  the  attack  of  arte- 
ritis of  the  trunk.  It  may  be  known  by  the 
sudden  onset  of  severe,  cramp-like  pains  in  the 
extremity  on  physical  movement  or  even  when 
the  patient  is  resting,  the  absence  of  the  peri- 
pheral pulse  being  probably  the  solitary  demon- 
strable sign.  An  interesting  point  which  should 
not  be  lost  sight  of,  is  that  pneumonia  is  apt  to 
supervene  in  such  cases  with  subsequent  spastic 
hemiplegia  in  the  right  side  of  the  body  and 


312  GENERALIZED   PAIN 

motoric  aphesia,  but  without  apoplectic  condi- 
tions. 

Arterial  pain  in  the  extremity  may  be  the 
sign  of  a  sudden  occlusion  of  one  of  the  branches, 
or  of  the  trunk  itself.  I  have  in  mind  here 
embolism  of  the  subclavian  or  brachial,  the  fe- 
moral or  popliteal  artery,  if  not  thrombosis.  If 
it  is  an  embolism  we  shall  have  no  difficulty  in 
finding  the  thrombotic  focus  nearly  always  in 
the  left  ventricle,  likewise  local  asphyxia,  sudden 
loss  of  pulsation,  icy  coldness,  hyperthesia  and 
anesthesia  with  secondary  symptoms  of  gan- 
grene. 

Of  course,  the  primary  thrombotic  focus  may 
also  be  localized  in  the  aorta  ( atheromatous 
ulcer)  or  in  the  pulmonary  veins  in  which  case 
it  will  be  beyond  recognition.  But  if  it  be  in 
the  heart  itself  we  are  dealing  with  a  recent 
endocarditis  or  a  thrombosis  in  the  left  side  of 
the  heart,  i.e.,  either  in  the  left  ventricle  or  in 
the  left  auricle.  In  the  latter  instance  stenosis 
of  the  mitral  ostium  is  the  cause  of  the  throm- 
botic condition.  A  ball  thrombus  is  distinguished 
by  mitral  stenosis  and  supervening  gangrene  in 
both  lower  extremities.  This  gangrene  may 
originate  either  from  thrombosis  of  the  arteries 
in  the  legs,  or  from  an  embolism  generated  by 
the  ball  thrombus  in  the  auricle.  When  the 
embolism  affects  both  popliteal  arteries  and  runs 
parallel  with  an  ascending  thrombus  in  both, 


EXTREMITIES  313 

an  occlusion — though  not  necessarily  total— of 
both  femoral  arteries  is  the  natural  result. 

There  is  still  another  form  of  occlusion  of  the 
arteries  either  in  both  legs  or  in  one  only  which 
is  attended  with  most  maddening  pains  in  the 
occluded  area.  Here  mitral  stenosis  generates 
thrombosis  in  the  left  auricle  with  a  subsequent 
embolism  of  the  abdominal  aorta.  The  end 
result  is  an  embolism  of  the  common  iliac  artery, 
with  severe  pains  in  the  abdomen  and  legs. 
Paresthesia  may  have  preceded  or  may  accom- 
pany the  attack,  but  there  is  no  definite  change 
in  the  arterial  pulse.  On  the  other  hand  motoric 
weakness  and  decline,  if  not  total  absence  of  the 
patellar  reflexes  is  always  noticeable.  The  pains 
gradually  subside  only  to  come  on  again  sud- 
denly with  renewed  vigor,  at  first  in  one  leg 
only  from  the  knee  down  to  the  toes.  This  is 
followed  by  missing  pulsation  in  the  arteries  of 
the  foot,  pallor  and  coldness  in  the  foot  and  in 
a  part  of  the  leg  and  anesthesia.  The  process 
repeats  soon  after  in  the  other  leg  also.  What 
I  have  said  is  taken  from  my  own  practical 
experience. 

In  some  cases  thrombosis  or  an  embolism  of 
the  abdominal  aorta  localized  in  the  bifurcation 
of  the  common  iliac  artery  alone  is  sufficient  to 
produce  a  high  grade  ischemia  in  it  and  in  its 
branches.  We  find  pains  in  the  abdomen  and 
in  the  lower  extremities  (sometimes  in  the  lower 


314  GENERALIZED   PAIN 

part  only),  pale  appearance  of  the  skin  which 
feels  cold  to  the  touch,  hypesthesia  and  anes- 
thesia, missing  or  very  small  peripheral  arterial 
pulse,  painful  paraplegia  and  gangrene.  I  have 
seen  cases,  however,  in  which  all  these  symptoms 
were  wanting,  but  instead  I  found  a  very  pro- 
nounced stenosis  of  the  mitral  ostium  with 
thrombosis  of  the  left  auricle,  and  in  all  toes 
and  their  adjacent  parts  symmetrical  signs  of 
a  very  severe  venous  stasis  and  arterial  ischimia, 
strongly  resembling  initial  gangrene.  And  yet 
there  was  no  evidence  of  thrombosis  or  embolism 
of  the  arteries,  but  anatomico-histological  signs 
of  severe  venous  stasis  with  secondary  terminal 
thrombosis  of  the  venous  trunks  and  strong 
constriction  of  the  arteries  could  be  noticed. 

When  an  embolism  in  the  branches  or  in  the 
trunk  of  an  artery  in  the  lower  extremity  or 
in  the  region  of  the  abdominal  aorta  produces 
sudden  very  intensive  pains,  a  mistaken  diag- 
nosis of  neuralgia  is  frequently  made.  The  same 
may  be  said  with  equal  force  of  thrombosis, 
especially  in  the  initial  stages  of  the  disease  and 
before  a  secondary  constricting  and  occluding 
thrombosis  has  supervened.  The  symptoms  of 
local  asphyxia  and  gangrene  are,  of  course,  the 
same  in  both  cases,  for  which  reason  the  differ- 
ential diagnosis  is  sometimes  hard  to  make  unless 
synchronous  abdominal  pains  indicate  the  locali- 
zation of  the  occlusion. 


EXTREMITIES  315 

Arterial  constriction  is  always  a  possibility 
when  the  patient  complains  of  continuous  pains 
in  one  of  the  extremities  or  in  a  distal  part 
thereof  no  matter  whether  paresthesia  is  in  evi- 
dence or  not. 

All  that  has  been  said  in  the  foregoing  pages 
about  pains  in  the  lower  extremities  applies  in 
like  manner  to  the  upper  extremities.  It  should 
not  be  difficult  to  recognize  analogous  affections 
of  the  anonyma  or  the  subclavian  artery. 

In  the  chapter  on  "Muscular  Pain"  I  have 
already  said  that  severe  pains  in  the  extremities 
may  arise  from  an  attack  of  periarteritis  nodosa, 
for  which  reason  I  only  mention  the  subject 
here. 

I  will  now  speak  of  morbid  conditions  in 
the  veins  as  a  possible  source  of  pains  in  the 
extremities. 

Acute  thrombophlebitis  occurs  more  frequently 
in  the  lower  extremities  and  is  attended  by  very 
severe  pains,  a  climbing  pulse  and  premonitory 
rise  in  the  temperature.  Fever,  edematous  con- 
ditions along  the  entire  course  of  the  affected 
vein  (marantic  thrombosis  in  the  radicular  zone), 
local  painfulness  and  the  unyielding  consistence 
of  the  vein  when  palpated  are  adequate  symp- 
toms for  a  correct  diagnosis  which  may  be 
further  strengthened  by  the  consecutive  forma- 
tion of  collateral  cutaneous  veins  or  the  accession 
of  a  pulmonary  embolism  or,  if  the  foramen 


316  GENERALIZED   PAIN 

ovale  be  open,  of  paradox  embolism.  These 
symptoms  are  not  always  very  distinct,  but  the 
painfulness  of  the  affected  vein  and  the  differ- 
ence in  the  local  temperature  will  help  us  to 
avoid  an  error. 

When  once  satisfied  that  we  are  dealing  with 
a  case  of  thrombophlebitis  we  shall  have  to  hunt 
for  the  originating  factor.  It  behooves  us  here 
to  consider  that  the  cause  of  the  affection  may 
not  only  be  an  infection  localized  in  the  radicular 
zone  of  the  vein,  but  may  just  as  well  consist 
of  an  inflammation  in  any  part  of  the  venous 
wall.  I  call  attention  to  the  frequency  of  phle- 
bitis in  the  lower  extremities  when  the  patient 
is  suffering  from  an  infectious  disease  of  the 
uterus  (puerperal  thrombosis),  to  other  morbid 
processes  in  the  small  pelvis  or  in  the  retroperi- 
toneal  space,  e.g.,  of  the  male  genitals  or  the 
bladder,  appendicitis,  perityphlitis,  pericolitis, 
perisigmoiditis,  acute  ulcerous  colitis,  perine- 
phritis,  pyelitis,  renal  neoplasm  or  a  disease  of 
the  pelvic  bones.  Phlebitis  may  also  have  its 
genesis  in  a  general  septic  infection,  e.g.,  ty- 
phoid, influenza,  smallpox,  syphilis,  etc. 

Marantic  or  cachectic  thrombosis  is  the  sequel 
of  insufficient  cardiac  action,  of  generalized 
cachexia,  severe  anemia,  or  venous  constriction 
due  to  encroaching  tumors  or  else  to  dilatation 
of  the  veins,  etc.  The  pains  arrive  suddenly 
generally  in  one  of  the  lower  extremities  with 


EXTREMITIES  317 

local  coldness  and  blue  pigmentation  of  the  skin. 
A  thrombus  can  be  palpated  in  the  vein  which 
feels  like  a  quill,  the  distal  collateral  veins  are 
enlarged  (frequently  the  first  and  solitary  sign 
of  the  thrombotic  condition)  to  which  may  be 
added  an  edema  in  the  radicular  zone  of  the 
morbid  vein.  But  I  warn  the  observer  not  to 
take  such  an  edema  as  a  conditio  sine  qua  non. 
Many  errors  have  sprung  from  this  assumption, 
because  in  many  cases  it  does  not  exist,  espe- 
cially when  the  affection  is  in  the  deeper  muscu- 
lar veins.  The  presence  of  pain — mild  though 
it  be  in  many  instances — of  local  sensitiveness, 
enlargement  of  the  collateral  cutaneous  veins, 
no  doubt,  will  guide  our  judgment  in  such  cases, 
particularly  when  we  are  able  to  palpate  the 
hard,  waxy  consistence  of  certain  neighboring 
muscles. 

The  next  thing  to  do  is  to  ascertain  the  pri- 
mary cause  of  the  disease.  With  regard  to  that 
I  repeat  again  that  not  only  local  defects  in 
the  circulation  such  as  varicose  veins,  or  con- 
traction of  the  venous  trunks,  but  also  general- 
ized infections  may  breed  such  thromboses.  We 
call  them  cachectic  thromboses  because  they  may 
follow  after  any  form  of  cachexia. 

Every  case  of  thrombosis  in  the  extremities 
is  a  warning  signal  of  a  latent  carcinoma,  and 
in  the  same  measure,  thrombosis  in  a  vein  of 
the  arm  points  to  an  expanding  morbid  process 


318  GENERALIZED   PAIN 

in  the  mediastinum  with  constriction  of  the  supe- 
rior vena  cava.  Be  it  remembered  that  throm- 
bosis of  the  superior  as  well  as  the  inferior  and 
also  of  the  iliac  vein  is  hardly  ever  associated 
with  pain,  because  it  seems  to  me,  the  affected 
extremity  derives  a  competent  supply  of  blood 
from  collateral  veins,  which,  however,  is  not  the 
case  when  the  principal  vein  is  choked  up.  Per- 
haps, this  explains  the  occurrence  of  thrombosis 
in  the  inferior  vena  cava  with  edema  in  only 
one  of  the  lower  extremities. 

Thrombophlebitis  or  phlebothrombosis  of  this 
kind  in  one  of  the  lower  extremities  is  indicated 
when  the  patient  complains  of  sudden  pains  in 
the  affected  part,  when  we  find  livid  coloration, 
coldness,  wanting  pulse,  anesthesia  and  initial 
gangrene.  As  a  rule  we  are  inclined  to  ascribe 
these  symptoms  to  a  defect  in  or  an  arrest  of 
the  arterial  circulation,  e.g.,  arteriosclerosis,  end- 
arteritis,  embolism  or  thrombosis.  And  yet  an 
error  may  creep  in  as  I  know  from  personal 
experience.  In  one  case  the  post  mortem  showed 
a  recent  endocarditis;  while  the  arteries  in  the 
legs  were  quite  intact  there  was  thrombophebitis 
of  both  the  crural  veins. 

Another  case  presented  an  ulcerating  carci- 
noma of  the  stomach  in  a  man  over  60  years  old, 
who  three  days  before  his  death  suffered  keen 
tearing  pains  in  the  left  foot  with  coldness, 
cyanosis,  wanting  pulse  and  anesthesia.  The 


EXTBEMITIES  319 

post  mortem  showed  a  marantic  thrombosis  of 
the  left  popliteal  vein,  very  rigid  arteries  and 
atrophy  of  the  heart. 

A  third  case  was  that  of  a  female  patient, 
fifty-one  years  of  age,  who  was  afflicted  with 
stenosis  of  the  mitral  ostium,  insufficiency  of  the 
mitral  valve  and  of  the  heart.  The  post  mortem 
revealed  defective  arterial  circulation  causing 
venous  stasis,  secondary  venous  thrombosis  and 
the  clinical  symptoms  of  an  initial  gangrene 
which  could  not  be  anatomically  recognized. 

Simple  phlebosclerosis  and  also  phlebectasia 
lead  to  paresthesias,  an  individual  form  of  inter- 
mittent dysbasia,  and  rather  moderate,  dragging 
pains,  especially  in  the  calves.  We  find  trem- 
bling, tension,  a  feeling  of  heat  and  itching  in 
the  lower  extremities,  symptoms  which  are  sharp- 
ened by  standing  or  otherwise  overtaxing  the 
muscles  of  the  extremities.  The  pains  come  on 
also  when  the  patient  has  been  walking  a  long 
distance  or  is  carrying  a  heavy  burden,  but 
disappear  when  he  quickens  the  pace  or  is 
climbing  steps.  The  diagnosis  has  already  been 
discussed  but  I  will  add  that  here,  too,  mistakes 
may  be  made  when  the  pains  announce  them- 
selves in  an  unwonted  fashion.  Flat  foot  and 
varicose  veins  are  possible  sources  which  are 
frequently  overlooked. 

Phlebosclerosis  bears  the  same  stigmata  as 
phlebectasia.  The  most  prominent  among  them 


320  GENERALIZED   PAIN 

is  thickening  of  the  venous  walls,  easily  demon- 
strated by  clinical  means  and  the  X-ray.  Edema 
of  the  knuckle  is  common  to  both.  It  becomes 
troublesome  in  the  evenings  and  if  the  disease 
is  protracted  it  may  assume  proportions  which 
resemble  elephantiasis.  The  overlying  skin  is 
rigid  and  immovable  but  pigmented  with  a 
diffuse  brownish  tint  owing  to  frequent  local 
hemorrhages. 

The  same  symptoms,  i.e.,  pain,  edema  and 
perceptible  enlargement  of  the  collateral  veins 
are  attached  to  chronic  phlebitis.  It  can  be 
distinguished  from  simple  phlebectasia  by  the 
intercurrent  acute  exacerbation  of  the  inflam- 
mation and  by  the  proof  that  it  arose  from  an 
acute  attack. 

It  is  self-evident  that  pains  in  the  lower  ex- 
tremities, especially  in  the  calves,  belong  to  the 
initial  signs  of  a  beginning  congestion  in  the 
inferior  vena  cava  and  in  consequence  of  muscu- 
lar insufficiency  of  the  heart.  The  other  symp- 
toms of  the  latter  such  as  fatigue,  headache, 
dyspepsia  and  dyspnea  will  assist  the  diagnosis 
materially. 

Inflammatory  wandering  diseases  of  the  lym- 
phatic vessels  are  also  attended  with  pains  in 
the  extremities.  Acute  lymphangitis  as  well  as 
acute,  subacute  and  chronic  lymphadenitis  are 
frequent  causes  of  such  pains,  especially  in  the 
arms.  The  former  stands  out  by  the  manifesta- 


EXTREMITIES  321 

tion  of  chills  and  fever,  general  indisposition, 
long  streaks  of  reddening,  slight  infiltration  but 
very  decided  painfulness  of  the  affected  parts. 
Lymphadenitis,  on  the  other  hand,  is  distin- 
guished by  painful  swelling  of  one  or  more 
lymphatic  glands,  especially  in  the  axilla  and  in 
the  groin. 

Pains,  swollen  lymphatic  glands,  edema  and 
infiltration  of  the  periglandular  skin  (hemor- 
rhages and  vesiculation)  and  absence  of  lym- 
phangitis are  the  most  prominent  signs  of 
bubonic  plague.  The  patient  complains  from 
the  very  beginning  of  pain  in  the  glandular 
region  (groin,  armpit,  neck)  and  of  local  ten- 
derness. 

The  seat  of  pain  in  the  extremities,  of  course, 
may  also  be  in  the  muscles,  in  the  nerves,  joints, 
tendons,  fascia,  ligaments  or  synovial  sacs,  in 
the  bones  or  in  several  or  all  of  these  organs. 
For  fuller  details  I  refer  the  reader  to  the  re- 
spective chapters  on  these  various  subjects  con- 
fining myself  in  this  place  to  the  discussion  of 
pain  arising  clearly  and  definitely  from  nervous 
disorders  only. 

III.  Pain  in  the  Nerves 

I  will  not  go  into  details  here  about  pains  in 
the  extremities  which  arise  from  peripheral  neu- 
ritis, but  only  mention  that  a  lesion  of  the  peri- 
pheral nervous  system  does  not  always  attack 


322  GENERALIZED   PAIN 

the  entire  system  in  equal  measure,  but  may 
only  affect  a  certain  portion  of  it;  for  instance, 
chronic  alcoholism  is  often  manifested  by  pains 
or  paresthesia  in  one  extremity  only.  Further- 
more, I  wish  to  point  out  that  in  neuritis  of  one 
nerve-trunk  the  pains  are  localized  solely  in  the 
distal  parts  of  the  affected  extremity  that  is  to 
say  in  the  peripheral  branches  of  the  nerve,  e.g., 
in  neuritis  of  the  ischiadic  nerve  (ischias)  the 
pain  exists  in  the  knee  or  in  the  heel,  or  in 
neuritis  of  the  brachial  plexus  it  is  in  the  tips 
of  the  fingers.  In  such  cases  the  behavior  of  the 
tendon  and  skin  reflexes  and  the  presence  of 
nerve-pressure  points  are  of  decided  diagnostic 
merit.  And  finally,  let  me  add,  that  injuries 
of  a  nerve  or  a  nerve-plexus  may  be  associated 
with  paresthesias  and  pains  not  only  in  the 
affected  extremity,  but  also  in  the  corresponding 
extremity,  no  doubt  via  the  shortest  route  of 
sympathetic  irritation. 

Pains  in  one  or  in  both  extremities  may  arise 
from  any  kind  of  morbid  conditions  which  irri- 
tate the  trunk  of  the  nerves  proximal  to  the 
extremity  or  the  radicular  zone  of  it  either  by 
compression  or  by  way  of  a  perineuritis.  We 
can  recognize  these  truncal  pains  by  their  irradi- 
ation into  the  appurtenant  branches,  by  synchro- 
nous paresthesia,  by  their  neuralgiform  character, 
their  permanence  with  periodic,  often  excessive 
exacerbations,  tenderness  in  the  nerve-trunks, 


EXTREMITIES  323 

sensitiveness  in  the  pertinent  muscles.  We  must 
also  look  for  sensible  and  motoric  disorders  in  the 
affected  nervous  area,  changes  in  the  tendon 
reflexes,  muscular  atrophy  and  fibrillary  twitch- 
ings  as  well  as  electric,  trophic  and  vasomotoric 
reactions.  Nevertheless,  there  are  cases  in  which 
some  if  not  all  of  the  aforementioned  symptoms 
are  wanting,  but  then  the  nerve  itself  will  very 
likely  make  itself  known  as  the  irritating  cause 
of  the  pain. 

If  the  pain  is  unilateral  its  originating  cause 
is  to  be  found  in  a  nerve-trunk  of  the  extremities. 
It  then  either  occupies  the  whole  bronchial  terri- 
tory or  is  confined  only  to  a  certain  area  of  the 
plexus,  most  frequently  in  the  distal  parts  of  the 
extremity. 

Apart  from  the  primary  diseases  of  the  nerve- 
trunks,  insofar  as  the  lower  extremities  are  con- 
cerned, we  must  also  consider  as  irritating  causes 
of  pain  all  morbid  processes  of  the  true  pelvis, 
of  the  retroperitoneal  space  and  of  all  organs 
that  for  morbid  reasons  may  in  any  way  en- 
croach on  this  cavity  which  is  so  to  speak  a 
common  meeting  place  of  all  sorts  of  pain.  It 
is  rather  of  interest  to  notice  that  even  in  affec- 
tions of  azygous  median  organs  in  this  region 
unilateral  pains  in  the  extremities  may  exist. 
For  instance,  pain  in  the  right  leg  makes  us  think 
of  prostatic  carcinoma.  Other  accompanying 
symptoms  will  help  us  to  find  the  right  diagnosis, 


324  GENERALIZED   PAIN 

for  instance:  parallel  irradiation  of  the  pains 
into  the  abdomen  and  genitals,  simultaneous 
psoas  position  as  a  sign  of  renal  or  pararenal 
(paranephritic)  inflammation  or  suppuration. 

Of  equal  importance  is  the  fact  that  similar, 
rather  light  pains  in  the  anterior  side  of  the 
thigh,  more  distinct,  however,  in  the  right  foot, 
combined  with  abdominal  and  sacral  pains  with 
fever  or  without,  with  vomiting  or  otherwise, 
are  an  indication  of  a  possible  acute  periappen- 
dicitis,  in  which  the  vermiform  appendix  presses 
on  the  psoas  muscle  and  produces  an  acute  initia- 
tion of  the  crural  nerves  (perineuritis  of  the 
crural  nerves).  In  these  cases  we  often  miss 
every  symptom  of  peritonitis,  chiefly  vomiting, 
and  the  stormy  onslaught  of  the  disease  alto- 
gether. The  diagnosis  is  materially  advanced 
by  the  radiating  nature  of  the  pain  in  the  foot 
and  by  the  fact  that  in  active  contraction  of  the 
psoas  muscle  (raising  of  the  foot)  the  local 
pressure  pain  in  the  ileocecal  region  is  much 
severer  than  when  the  leg  is  at  rest.  Palpation 
per  rectum  is  painful  and  there  is  considerable 
tension  of  the  abdominal  muscles.  The  patient 
feels  the  pains  in  the  thigh,  but  the  abdominal 
pains  do  not  seem  to  incommode  him  to  any 
extent.  That  the  abdominal  pains  are  either 
provoked  or  sharpened  by  movements  of  the 
hip  joint  appears  to  me  to  be  an  important  sign 
of  acute  or  chronic  periappendicitis. 


EXTREMITIES  325 

These  pains  in  the  anterior  side  of  the  thigh 
are  likewise  a  valuable  symptom  of  renal  dis- 
eases (tuberculosis,  neoplasm,  hydronephrosis) 
and  in  other  retro  peritoneal  affections.  Still,  we 
must  not  lay  too  much  stress  upon  this  sign, 
because  there  are  cases  of  intraperitoneal  tumors 
which  extend  so  far  rearwards  that  they,  too, 
may  give  rise  to  retroperitoneal  pains. 

In  paroodmal  hemoglobinuria  pains  are  expe- 
rienced in  the  lower  extremities  during  the  at- 
tack, but  they  are  superseded  by  those  in  the 
loins  and  in  the  region  of  the  spleen  and  liver. 

Pains — and  casually  paresthesia — on  the  inner 
side  of  the  thigh  down  to  the  knee  together  with 
signs  of  sudden  incarceration  are  the  strongest 
hints  of  an  existing  hernia  obturatoria.  Distinct 
painfulness  on  deep  pressure  against  the  fora- 
men obturatorium  and  a  slight  arching  in  the 
region  of  the  oval  perforation  confirm  the  diag- 
nosis. 

A  unilateral  pain  in  the  upper  extremity  in- 
troduced or  accompanied  by  paresthesia  warns 
of  an  expanding  morbid  process  in  the  medias- 
tinum. In  my  own  opinion,  which,  however,  is 
not  shared  by  all  authorities,  pains  in  the  right 
— very  seldom  in  the  left — arm  (and  shoulder) 
point  to  an  aneurysm  of  the  ascending  aorta  or 
its  arc,  likewise  to  solid  or  cystic,  less  frequently 
chronic  inflammatory  tumors  of  the  mediastinum, 
especially  of  the  glands  therein  (lymphogranu- 


326 

lomatosis).  According  to  their  anatomical  lo- 
calization these  tumors  produce  pains  in  one  of 
the  arms,  but  also  in  both.  These  pains  and 
possible  parenthesias  are  at  times  the  sole  symp- 
tom of  the  prevailing  disease  and  as  such  are 
of  signal  merit  for  the  diagnosis. 

Only  a  few  cases  are  on  record  in  which  acute 
processes  in  the  mediastinum  provoked  pains  in 
an  arm,  but  not  also  at  the  same  time  in  the 
chest  or  back.  I  do  not  speak  here  of  pericar- 
ditis when  the  pains  radiate  into  the  left  arm 
as  is  their  wont  in  angina  pectoris. 

These  pains  in  the  extremities  have  a  special, 
characteristic  habit  of  setting  in  when  the  patient 
is  lying  on  his  back  but  to  vanish  when  he  bends 
over  forwards.  The  same  happens  also  in  aneu- 
rysms  of  the  aorta  and  solid  tumors  of  the  medi- 
astinum. In  the  prone  position  the  aneurysm 
or  tumor  tears  and  presses  on  the  adjacent 
nerves  and  thus  exacerbates  the  pains,  which, 
however,  may  also  be  sharpened  by  physical 
overexertion. 

Tumors  of  the  superior  pulmonary  lobes  and 
acute  as  well  as  chronic  inflammatory  diseases 
thereof,  e.g.,  of  the  pleural  apex  give  rise  to 
analogous  irritation  of  the  cervico-brachial  plexus 
in  the  supraclavicular  region  and  hence  to  neuro- 
genous  pains  in  the  arm.  They  must  always 
remind  us  of  lobar  pneumonia  (with  pleurisy 
of  the  apices  and  perineuritis  of  the  cervical 


EXTREMITIES  327 

plexus)  or  of  acute  apical  pleurisy,  or  chronic, 
retracting  lobar  indurations  of  tuberculous  gene- 
sis or  otherwise,  also  of  tumors  in  the  same 
locality,  i.e.,  the  pleura.  Mark  this  also:  remit- 
tent-interremittent  pains  in  one  arm  are  the  first 
signs  of  carcinoma  in  the  upper  pulmonary  lobe 
or  its  pleural  apex,  or  in  the  main  bronchus. 

It  is,  perhaps,  easier  to  understand  that  an 
analogous  irritation  of  the  aforesaid  plexus  with 
subsequent  pains  in  the  arm,  paresthesia,  like- 
wise hyperesthesia,  weakness,  paresis,  apoplexy, 
may  also  emanate  from  any  expanding  or  in- 
flammatory morbid  condition  in  the  supraclavi- 
cular  fossa  (diseases  of  the  lymphatic  glands, 
of  the  clavicle,  aneurysm  of  the  subclavian  artery 
or  of  the  anonyma,  etc.).  The  diagnosis  comes 
easy  because  the  disease  is  open  to  our  senses, 
we  can  see  it,  we  can  feel  it.  Of  course  we 
cannot  look  upon  this — if  we  except  metastatic 
tumors  (glands) — as  a  definite  proof  that  the 
place  of  origin  of  the  tumor  and  of  the  subse- 
quent pains  in  the  arm  was  from  the  very  start 
localized  in  the  supraclavicular  fossa.  There 
are,  indeed,  cases  in  which  the  patient  complains 
of  pains  in  the  arm  but  not  a  trace  of  tumor  in 
the  supraclavicular  fossa  can  be  found  in  the 
beginning,  although  it  puts  in  appearance  later 
on:  in  other  words  the  original  mediastinal 
malign  tumor  has  forced  its  way  into  the  supra- 
clavicular  fossa. 


328  GENERALIZED   PAIN 

If  we  overlook  this  point,  if  the  anamnesis  is 
incomplete  and  we  have  neglected  to  make  a 
scrupulous  examination  of  the  whole  chest — not 
to  forget  the  X-ray — we  may  readily  meet  with 
bitter  disappointments. 

Palpation  and  perception  of  the  supraclavi- 
cular  fossa  at  times  yield  absolutely  negative 
results.  A  cervical  rib,  for  instance,  may  escape 
our  observation  for  a  considerable  time,  although 
it  be  the  sole  cause  of  unilateral  or  dual  pains 
in  the  upper  extremities.  They  are  produced 
by  motation,  or  under  the  influence  of  cold, 
ushered  in  by  paresthesia,  associated  with  mo- 
toric,  trophic  and  secretory  troubles,  sensibility 
disturbances  (i.e.,  typical  neuritic  disorders), 
high  pressure  in  the  subclavian  artery,  with 
whirring,  hissing,  blowing  systolic  noises  above 
it.  Only  the  most  thorough  palpation  and  the 
X-ray  are  able  to  discover  the  true  source  of 
the  pains.  What  has  been  said  may  also  be 
applied  to  malignant  struma. 

The  aforesaid  intrathoracic  diseases  require 
equally  our  attention  where  the  pains  in  an  arm 
are  the  reflex  action  of  pains  in  the  chest,  but 
if  they  are  reflected  from  pains  in  the  abdomen 
(epigastrium,  hypochondrium)  they  indicate 
subdiaphragmatic  irregularities  and  go  in  com- 
pany with  pains  in  the  shoulder.  Witness  chole- 
lithiasis, perihepatitis  and  perisplenitis,  gastric 
diseases  (ulcer,  carcinoma,  perigastritis)  and 


EXTREMITIES  329 

diseases  of  the  pancreas.  In  some  cases  the 
pains  may  constitute,  when  of  a  neuralgiform 
character,  the  first  symptom,  e.g.,  of  ulcus  ven- 
triculi  in  the  left  brachial  plexus. 

Unilateral  neurogenous  pain  localized  cen- 
trally from  the  process  of  the  extremity  is  not 
only  due  to  an  affection  of  the  nerve  trunk 
beyond  the  extremity  but  may  just  as  well  origi- 
nate from  a  morbid  condition  in  the  intrasjnnal 
nerve  roots.  Of  course,  analogous  painfulness 
in  the  contralateral  extremity  matures  during 
the  course  of  the  disease.  The  bilateral  and 
symmetrical  nature  of  the  pains  constitutes  the 
characteristic  sign  of  these  lesions  of  the  nerve 
roots  because  their  fibres  lie  so  close  together. 
Nevertheless,  a  regional  disease  can  just  as  well 
have  a  unilateral  influence  on  the  nerve  roots. 

The  question  arises  here  how  to  differentiate 
between  affections  of  the  roots  and  those  of  the 
nerve-trunks.  In  the  first  place  it  is  important 
to  note  that  in  fascicular  (trunk)  affections 
objective  pressure  sensibility  is  present  in  the 
entire  nerve  trunk  (I  mean  isolated  pressure 
points)  which  in  affections  of  the  roots  are  either 
totally  wanting  or  of  a  negligible  quantity,  while 
in  their  place  pressure  points  in  the  spinous 
processes  are  to  be  found.  Secondly,  the  pains 
have  a  radicular  character,  that  is  to  say  they 
are  as  in  tabes  very  keen  lancinating  pains  pro- 
voked by  motation  or  overexertion,  hyperactivity 


330  GENERALIZED  PAIN 

of  the  abdominal  press,  e.g.,  when  sneezing.  In 
the  third  place  in  radicular  neuritis  not  the  whole 
plexus,  but  only  one  or  several  branches  are 
involved.  Fourthly  in  radicular  neuritis  objec- 
tive sensibility  disturbances  are  of  frequent 
occurrence  while  in  truncal  neuritis  they  are 
inconstant.  And  lastly  in  radicular  neuritis  the 
objective  sensibility  disturbances  run  in  the 
spinal-segmental  type,  i.e.,  generally  at  the  ex- 
tremities in'  horizontal  but  in  the  thorax  in 
circular  patches,  whilst  in  truncal  neuritis  they 
follow  the  peripheral  type,  i.e.,  the  direction  of 
the  peripheral  nerves. 

Unilateral  pain  in  the  upper  or  lower  extremi- 
ties or  in  both  or  only  in  a  section  of  one  points 
to  a  possible  cerebral  genesis.  I  do  not  refer 
here  to  the  sensible  aura  of  epilepsy  or  to  hemi- 
plegia,  but  rather  to  those  very  molesting  and 
severe  attacks  of  exacerbating  neuralgiform 
pains  which  manifest  themselves  in  hemiplegic 
extremities,  especially  the  arms.  Sometimes  they 
accompany  hemiplegia,  at  other  times  they  fol- 
low in  the  wake  of  it  or  arrive  before  the  attack 
sets  in  in  the  form  of  premonitory  pains  owing 
to  irritation  of  the  intracerebral  sensible  course 
through  the  central  focus  (focus  of  hemorrhages 
or  softening,  cysts,  tumors)  or  arising  from  the 
meninges.  Paresthesias  associated  with  these 
eccentric  pains  originate  from  certain  centers  in 
the  cortex,  or  in  the  vicinity  of  the  thalamus 


EXTBEMITIES  331 

opticus,  or  in  the  pons  or  the  cerebellum.  We 
can  localize  the  cerebral  seat  of  the  pain  by  the 
fact  that  other  cerebral  manifestations  accompany 
it,  i.e.,  hemiparesis,  hemiplegia,  hemispasms, 
hemiclonus,  hemiathetosis  or  hemianesthesia  in 
the  opposite  side  (hemianesthesia  dolorosa — thal- 
amus  affection). 

In  some  rare  cases  we  have  to  deal  with  sensi- 
ble manifestations  of  this  kind  only.  Then  the 
diagnosis  will  be  guided  either  by  changes  in  the 
tendon  or  skin  reflexes  or  of  the  deep  sensibility 
(stereognostic  sense),  or  by  other  cerebral  local 
or  generalized  symptoms,  or  perhaps  solely  by 
the  anamnesis  in  the  sense  of  a  preceding  apo- 
plectiform  insult  (in  a  thalamus  focus  not  recog- 
nizable!). These  pains  of  cerebral  origin  in 
hemiplegic  extremities  are  unfortunately  too 
often  taken  for  rheumatic  pains  because  they  are 
like  those  lancinating  pains  in  diseases  of  the 
spinal  cord  so  much  influenced  by  weather  con- 
ditions. I  mention  here  that  the  same  character- 
istics attach  also  to  pains  which  are  based  on 
anatominal  lesions  (stenocardia)  or  on  functional 
disorders  (neuroses). 

Of  interest  are  also  the  attacks  of  pain  in  an 
arm  or  leg  attended  with  high  fever  and  hyper- 
algesia  which  come  on  sporadically  in  progressive 
paralysis  and  disappear  again  within  a  few 
hours.  They  are  undoubtedly  of  central  origin 
and  will  be  properly  understood  if  we  take  into 


332  GENERALIZED   PAIN 

consideration  the  other  psychic  and  somatic  signs 
of  the  disease  as  well  as  the  anamnesis,  and  apply 
the  Wassermann  reaction  and  lumbar  puncture 
(three  tests). 

It  is  easy  to  understand  that  in  neuritis  the 
pains  are  present  in  the  affected  nerve-trunks  in 
both  sides  and  frequently  assume  the  role  of 
symptomatic  manifestations  of  the  causating 
disease,  e.g.,  chromic  alcoholism  or  leprosy,  mor- 
bid conditions  in  the  true  pelvis  or  in  the  retro- 
peritoneal  cavity.  So,  too,  a  bilateral  ischias  is 
a  valuable  indication  of  prostatic  carcinoma  or 
multiple  tumors  in  the  pelvis,  if  not  of  diabetes, 
malaria  or  gouty  diathesis  or  chronic  constipa- 
tion. Pains  in  both  the  lower  extremities  and 
in  the  hip  joints,  particularly  in  women,  are  the 
first  sign  of  tuberculous  peritonitis. 

Radicular  neuritis  and  spinal  disorders  are 
further  irritating  factors  of  bilateral  pains  either 
in  the  upper  or  in  the  lower  extremities.  I  refer 
to  tumors,  tuberculosis,  gummata  of  the  verte- 
bras, compression  of  the  intraspinal  ganglia, 
morbid  conditions  in  the  meninges  and  intra- 
medullary  diseases.  Likewise  to  multiple  scle- 
rosis, syringomyelia,  myelitis,  cerebro-spinal 
syphilis,  tumors  of  the  spinal  cord,  acute  polio- 
myelitis, chronic  meningitis,  epidemic  cerebro- 
spinal  meningitis,  tabes  superior,  pachymenin- 
gitis  (chronic  hemorrhagic,  syphilitic  or  tuber- 
culous), hemorrhages  in  the  spinal  cord  (trau- 


EXTREMITIES  333 

matic),  in  hemorrhagic  diathesis,  scarlet  fever, 
scurvy,  pernicious  anemia,  and  tumors  of  the 
spinal  cord  (extramedullary). 

Also  leucemic  or  lymphoid  infiltrations  in  the 
epidural  tissue  of  the  lower  vertebral  canal 
deserve  mention  here.  In  vertebral  insufficiency 
it  will  be  noted  that  pains  in  the  spinal  column 
or  in  the  back  are  of  rare  occurrence,  as  they 
predominate  in  the  chest  and  abdomen,  legs  and 
arms.  If  we  have  proof  of  sensitiveness  on 
pressure  and  percussion  in  a  definite  zone  of  the 
spinous  processes,  if  we  find  spasms  in  the  dorsal 
muscles,  collapse  of  the  spinal  column  or  deform- 
ing curvature  of  the  body  with  relaxation  of 
these  symptoms  when  the  patient  is  resting,  we 
should  have  no  difficulty  in  forming  a  satisfac- 
tory diagnosis. 

I  include  those  extremity  crises  in  tabes  dor- 
salis  in  which  the  patient  complains  of  violent, 
dragging  and  tearing  pains  with  subsequent 
cramps  in  the  calves  and  local  hyperesthesia. 
Likewise  those  pains  in  the  lower  extremities 
which  follow  the  interspinal  injection  of  a  cold 
fluid  not  properly  warmed  up,  and  also  those 
very  keen  pulling  pains  in  the  arms  and  legs  of 
which  we  see  so  much  in  epidemic  encephalitis— 
the  latter,  however,  may  be  also  due  to  purely 
cerebral  influences. 

Pellagra  generally  sets  in  with  pains  and  par- 
esthesia  in  the  extremities,  no  matter  whether  it 


334  GENERALIZED   PAIN 

affects  the  spinal  cord  or  the  peripheral  nervous 
system. 

In  paraplegia  dolorosa  we  witness  intensive 
pains  in  the  back  which  radiate  thence  into  the 
paralyzed,  debilitated  extremities.  Carcinoma  of 
the  spinal  column  is  the  most  pronounced  char- 
acteristic of  this  disease,  a  fact  which  accounts 
for  the  violent  pains  mentioned  just  now. 

In  the  diseases  heretofore  discussed  the  pains 
are  wont  to  sneak  in  gradually  and  increase  in 
intensity  more  or  less  rapidly.  But  there  are 
other  chronic  affections  of  the  spinal  cord  and 
its  membranous  envelope  as  well  as  of  the  os- 
seous parts  which  introduce  themselves  with  a 
very  sudden,  apoplectiform  initial  pain  in  one 
if  not  in  both  corresponding  extremities.  I  am 
not  referring,  however,  to  tuberculous  spondi- 
litis,  but  rather  to  extramedullary  tumors  of  the 
spinal  cord  which  after  a  slow  latent  growth 
suddenly  spring  into  evidence  with  a  stroke-like 
terrible  pain  in  the  extremities.  Their  invasion 
which  is  accompanied  by  a  feeling  as  if  the  spinal 
cord  were  severed  in  two  must  arouse  in  us  at 
once  the  suspicion  of  hematomyelia.  Although 
this  disease  is  in  itself  pregnant  with  pains,  still 
it  is  wise  even  here  to  remember  that  the  greater 
the  intensity  of  pain,  the  stronger  is  the  proba- 
bility of  a  membranous  involvement  of  the  spinal 
cord. 

A  hemorrhage  as  well  as  a  sudden  vascular 


EXTREMITIES  335 

occlusion  of  the  spinal  cord  leads  to  very  severe 
pains  in  the  lower  extremities  with  a  quick  local 
relaxation  in  the  power  of  motion  and  with 
sensibility  disturbances  reaching  even  into  the 
hypochondrial  region,  witness  certain  cases  of 
dissecting  aneurysm  of  the  thoracic  aorta  with 
hemorrhage  into  the  aortic  tube  cutting  the  circu- 
lation in  a  portion  of  the  intercostal  arteries. 

An  ordinary  aneurysm  of  the  descending  thor- 
acic aorta  (also  of  the  abdominal  aorta)  is  in  the 
same  manner  liable  to  produce  paresthesia  and 
pain  in  the  lower  extremities  through  spinal 
influence,  i.e.,  when  a  vertebra  is  worn  down  by 
friction  and  an  opening  into  its  canal  is  formed 
which  naturally  results  in  pressure  on  the  spinal 
cord.  The  superceding  symptoms  of  the  trans- 
section  of  the  spinal  cord  (backache,  paraparesis 
or  paraplegia  of  the  legs,  gastric  and  bladder 
troubles,  etc.)  should  put  the  diagnosis  on  a 
sound  foundation.  To  find  the  cause  for  it  in 
an  aneurysm  of  the  aorta  may  be  difficult  at 
times,  but  the  difference  in  the  arterial  pulses 
of  the  upper  and  lower  extremities  and  the 
X-ray  are  reliable  guides  in  that  direction. 

Unilateral  and  why  not  bilateral  pain  in  the 
nerves  of  the  extremities,  however,  are  not  only 
dependent  on  neuralgia  or  apparently  neuralgic 
conditions,  but  may  just  as  well  originate  from 
any  common  cause. 

Certain  infectious  diseases,  such  as  malaria, 


336  GENERALIZED   PAIN 

syphilis,  gonorrhea,  tuberculosis,  typhoid,  influ- 
enza, etc.,  are  creators  of  neuralgia  in  its  divers 
forms.  Exogenous  and  endogenous  intoocica- 
tions  are  frequently  at  the  bottom,  such  as  dia- 
betes mellitus,  hyperglycemia,  gout,  uremia, 
chronic  obstipation,  alcohol,  lead,  arsenic,  car- 
bon dioxid  poisoning,  in  fact  all  disorders  of 
metabolism. 

For  the  sake  of  substantiating  this  claim  I 
will  pick  out  as  an  example  ischias.  When  the 
patient  complains  of  such  a  pain  in  the  ischiadic 
plexus  we  must  be  conscious  of  the  fact  that  it 
is  due  to  a  lesion  either  of  the  corresponding 
nerve-roots  or  of  the  nerve-trunks.  But  we 
should  also  remember  that  there  is  such  a  thing 
as  ascending  neuritis  (though  very  seldom  ap- 
plicable in  ischias) ;  in  other  words  that  an 
infectious  disease  in  the  radicular  zone  of  a 
nerve  may  lead  to  an  ascending  inflammation 
of  the  trunk  and  its  branches.  From  this  we 
are  safe  to  draw  the  conclusion  that  in  cases 
of  ischias  we  have  before  us  a  long  string  of 
possible  complications. 

There  are  expanding  morbid  processes  of  all 
kinds  in  the  spinal  canal  whether  they  originate 
from  the  meninges  (pachymeningitis,  leptomen- 
ingitis,  tumors),  or  from  the  spinal  cord  proper 
or  from  the  cauda  equina  (tumor) ;  diseases  of 
the  nerve-roots  in  the  lumbo-sacral  vertebrae  and 
their  interarticular  ligaments  (neoplasms,  spondi- 


EXTREMITIES  337 

litis,  rhizomyelia)  or  in  the  intervertebral  fora- 
nina  (inflammatory,  neoplastic,  leucemic  infiltra- 
tions) ;  inflammatory  or  compressing  processes 
in  the  region  of  the  loins  and  sacrum,  no  matter 
whether  they  arise  from  affections  of  the  bones, 
of  the  connective  tissue,  or  of  retroperitoneal 
lymphatic  glands  or  organs  (kidneys,  adrenals) ; 
analogous  morbid  conditions  in  the  pelvic  area 
(pregnant  uterus,  tumors,  inflammations,  dis- 
eases of  the  ovaries,  of  the  prostate,  chronic 
constipation) ;  inflammatory  and  constricting 
processes  in  the  lower  extremities;  diabetes, 
gouty  diathesis,  malaria,  etc. 

Local  traumata,  diseases  or  infiltrations,  also 
sclerosis  of  the  arteries  (arteriosclerotic  neuritis), 
varices  of  the  venous  nerves,  all  these  conditions 
may  lead  to  ischias.  We  must  also  differentiate 
between  true  ischias  and  neurotic  (hysterical) 
pseudoischias.  So  far  as  the  latter  is  concerned 
we  must  fall  back  on  the  typical  characteristics 
of  hysteria,  the  fluctuating  localization  of  the 
pains,  the  fact  that  a  gentle  pinching  of  the  skin 
causes  severer  pain  than  hard,  deep  pressure 
and  that  the  pains  subside  under  the  influence 
of  mental  distraction.  The  diagnosis  finds  fur- 
ther subsidy  from  the  behavior  of  the  tendon 
reflexes  (decrease  of  the  achilles  tendon  reflexes 
in  true  neuritic  ischias),  from  the  special  char- 
acteristics of  the  pains,  the  pressure  points, 
Lasegue's  symptom,  increase  through  the  ab- 


338  GENERALIZED    PAIN 

dominal  press,  coldness  of  the  knees  and  last 
but  not  least,  from  the  Roentgen  ray, 

IV.  Other  Pains  in  the  Extremities 

All  these  symptoms  must  be  carefully  con- 
sidered whenever  we  hear  complaints  of  pain  in 
the  small  of  the  back  and  in  the  breast  and  the 
diagnosis  balances  between  ischias  and  lumbago. 
Incidentally,  these  two  diseases  may  run  a  paral- 
lel or  alternating  course,  unless  lumbago  is  in 
itself  a  neuritis  of  the  ischiadic  branches. 

Slight,  vague  pains  which  are  hard  to  localize 
in  the  muscles  and  which  radiate  into  the  bones 
and  joints  consisting  more  of  a  painful  drag- 
ging, but  acute  under  the  influence  of  general 
indisposition  and  mostly  attended  with  fever  are 
a  clear  indication  of  an  acute  infection.  Every 
form  of  infection,  every  kind  of  vaccination  may 
begin  with  these  sensations.  But  in  some  they 
are  more  pronounced  than  in  others,  the  com- 
monest among  them  being  the  ordinary  nasal 
catarrh  (coryza,  snuffles)  and  influenza  (grippe). 
(Cf.  chapter  on  "Muscular  Pains.")  In  small- 
pox, recurrent  fever  (pains  in  the  bones,  joints 
and  muscles,  especially  in  the  legs),  erysipelas 
(most  intensive  muscular  and  nervous  pains), 
but  also  in  influenza  these  pains  are  very  severe 
and  of  a  boring,  tearing  character  not  only  in 
the  incipient  stages,  but  throughout  the  run  of 
the  infection  and  sometimes  far  beyond  that. 


EXTREMITIES  339 

In  typhoid  and  paratyphoid  this  is  not  so  often 
observed.  Pappataci  fever  has  articular  pains, 
and  glanders  pains  in  the  shinbones  as  com- 
panions. 

In  spotted  typhus  paresthesia  and  pains  in 
the  extremities  are  not  only  the  expression  of 
the  generalized  infection,  but  may  also  be  the 
precursory  sign  of  gangrene  characteristic  of  this 
disease.  I  have  already  said  previously  that 
gangrene  of  the  extremities  follows  also  other 
acute  infections  such  as  typhoid,  influenza,  etc. 
In  all  these  diseases,  especially  in  exanthemic 
fever  the  pains  endure  at  times  for  weeks  with- 
out subsequent  gangrene.  They  are  evidently 
due  to  specific  attacks  of  arteritis. 

Of  Wolhyman  fever  another  causative  factor 
of  these  pains  I  have  spoken  already  in  several 
places. 

Pains  in  the  extremities  which  come  to  the 
fore  in  septic  diseases  must  remind  us  of  meta- 
static  conditions  in  the  bones  or  in  the  muscles 
such  as  abscess  or  necrotic  foci. 

Periarteritis  nodosa  is  often  surrounded  by 
symptoms  which  strongly  resemble  a  septic  af- 
fection. There  are  pains  in  the  extremities 
which  are  evidently  due  to  morbid  changes  in 
the  arterial  walls.  We  also  find  irregular  at- 
tacks of  fever,  anemia,  physical  debility,  tachy- 
cardia, leucocytosis,  polynucleosis,  edema  and 
nephritis,  articular  swellings,  cutaneous  hemor- 


340  GENERALIZED   PAIN 

rhages,  cyanosis,  dyspnea  and  abdominal  pains. 
The  diagnosis  (cf.  "Abdominal  Pains")  can 
only  be  secured  when  we  can  palpate  the  en- 
larged local  arterial  walls.  Syphilis  seems  to 
be  the  originating  cause  of  this  disease  in  some, 
but  by  no  means  in  all  cases. 

Pains  in  the  extremities  are  not  only  initial 
and  concomitant  symptoms,  but  may  also  be  the 
sequel  of  infectious  diseases,  i.e.,  signs  of  con- 
valescence, as  it  were.  The  patient  is  run  down 
and  feels  as  if  he  had  been  beaten  up  after  a 
severe  attack  of  influenza,  for  instance,  or  small- 
pox. The  same  may  happen  even  after  slight 
infections,  such  as  dysentery  which  was  taken  for 
simple  diarrhea,  a  short  acute  attack  of  gastro- 
enteritis. The  toxic  after-effects  retard  recovery 
and  bring  fatigue  and  pain  with  them. 

In  mild  forms  of  trichinosis  pains  in  the  limbs 
are  not  uncommon  although  they  do  not  bear 
the  stamp  of  characteristic  significance.  Yet 
when  they  are  associated  with  pains  in  the 
muscles  of  the  neck  and  chest  and  with  gastro- 
intestinal troubles,  they  should  be  of  assistance 
in  finding  the  right  solution,  especially  when  we 
detect  an  edematous  lesion  in  the  eyelid  and 
eosinophilia  in  the  blood. 

This  applies  also  to  mitigated  forms  of  acute 
articular  and  muscular  rheumatism.  Here  we 
get  a  hold  on  the  diagnosis  when  local  pressure 
sensitiveness  and  heavy  sweating  are  present. 


EXTREMITIES  341 

The  effect  of  salicylic  treatment  is  another 
adjuvant. 

Complaint  of  mild  pains — sometimes  very  per- 
turbing, boring,  tearing — especially  in  the  tibia 
is  an  introduction  to  scurvy. 

In  metabolic  infections  the  patient  is  apt  to 
localize  the  pains  in  the  joints  and  muscles  of 
the  extremities.  Upon  closer  scrutiny  we  find 
that  they  rather  affect  the  tendons  and  fascia, 
also  the  nerves  and  synovial  sacs.  I  am  refer- 
ring to  gout,  but  not  to  the  typical  acute,  nor 
the  irregular,  but  to  that  form  which  we  know 
as  gouty  diathesis  or  a  typical  irregular  gout 
not  dependent  on  previous  gouty  articular  affec- 
tions. The  pains  are  of  a  transient  nature  and 
wander  about  from  one  place  to  another.  Clini- 
cally speaking  there  are  no  typical  signs  of  gout 
and  the  diagnosis  must  be  in  most  cases  merely 
a  good  guess,  justifiable,  indeed,  in  stout  persons 
with  a  familial  gouty  record,  persons  who  in- 
dulge in  sumptuous  living,  meat  eaters,  persons 
who  eschew  green  vegetables  and  fruit,  "bon 
vivants."  They  generally  suffer  from  abdominal 
plethora,  hemorrhoids,  enlarged  liver,  skin  dis- 
eases, such  as  chronic  eczema,  also  from  urticaria 
and  chronic  dyspeptic  troubles.  We  find  neu- 
rasthenic symptoms  such  as  headache,  dizziness, 
migraine,  abnormal  irritability,  chronic  lassitude, 
etc.,  without  a  specific  causal  element.  Renal 
calculus  is  common  in  these  patients.  The 


342  GENERALIZED  PAIN 

diagnosis  derives  much  benefit  from  a  proper 
urinary  analysis  and  tentative  drug  treatment. 
According  to  my  own  very  wide  experience  this 
disease  is  very  common  among  city-dwellers  who 
eat  too  much  and  do  not  take  sufficient  physical 
exercise  and  are  hereditarily  predisposed  to  such 
attacks.  It  is  very  difficult  to  properly  localize 
the  pains  as  they  vary  so  much  in  different 
individuals  and  even  in  the  same  person  as  to 
time  of  appearance.  Yet  in  the  majority  of 
cases  we  shall  be  able  to  spot  a  typical  neuralgia 
(e.g.,  ischias),  pseudorheumatic  muscular  and 
articular  pains. 

Tarsalgia  must  be  mentioned  on  account  of 
its  close  connection  with  gout  and  diabetes  mel- 
litus.  The  patient  complains  of  dull,  though 
sometimes  very  severe  pains  in  the  heel  of  the 
foot,  especially  in  the  lower  plane  thereof,  corre- 
sponding with  the  process  of  the  achilles  tendon. 
Sometimes  the  outer  margin  of  the  heel  is  very 
sore  to  the  touch.  The  pathologic  anatomical 
causes  for  these  pains  (achillodynia)  are  quite 
a  few.  I  mention  affections  of  the  achilles  ten- 
don (peritendinitis  achillea,  recognized  by  a 
peculiar  friction  fremitus  in  the  movement  of 
the  tendon),  enlarged  synovial  sacs  which  can 
be  felt  with  the  finger,  morbid  condition  in  the 
calcaneum  or  in  the  peripheral  nerves  (e.g., 
diabetic  neuralgia  or  ischias),  inflammation  of 
the  local  adipose  tissue.  Some  authors  claim 


EXTREMITIES  343 

that  peripheral  arteriosclerosis  or  a  similar  affec- 
tion of  the  arteries  of  the  bones  is  a  causative 
factor  as  can  be  demonstrated  by  the  aid  of  the 
Roentgen-ray.  Tarsalgia  as  a  rule  is  bilateral 
with  pains  in  the  median  knuckle  or  correspond- 
ing with  the  cuboid  bone.  If  dealing  with  a 
traumatic  affection  of  the  synovial  sac,  or  an 
exostosis  of  the  calcaneum  (calcaneous  spur) 
(Roentgen  picture!)  it  is  of  importance  for  the 
internist  to  ascertain  whether  the  cause  is  not 
to  be  found  in  flat  foot,  or  gout  or  gonorrhea, 
or  else  in  rheumatic  conditions.  The  gonorrhoic 
form  is  distinguished  by  the  fact  that  the  pains 
are  not  only  centered  in  the  heel  but  involve 
also  the  sole  of  the  foot  (1.  to  5.  metatarsophal- 
angeal  joint). 

But  a  calcaneous  spur  may  also  be  congenital, 
or  due  to  syphilis,  a  trauma,  flat  foot  or  osteo- 
arthritis.  Bear  also  in  mind  that  pes  planus  and 
a  calcaneous  spur  may  co-exist. 

Pains  in  the  foot  are  also  due  to  affections  of 
the  plantar  aponeurosis,  viz.,  fasciitis  plantaria 
aponeurotica,  due  to  gout,  gouty  diathesis,  hence 
due  to  the  presence  of  urates  in  the  plantar 
fascia.  The  etiologic  diagnosis  is  based  on  the 
characteristics  of  gouty  conditions.  It  is  also 
claimed  that  rheumatic  indurations  in  the  plantar 
fascia  give  rise  to  local  pains. 

Acute  fasciitis  is  also  among  the  sequels  of 
acute  infections,  especially  of  influenza,  and  may 


344  GENERALIZED   PAIN 

be  recognized  by  radiating  pains  and  tenderness 
in  and  around  the  aponeurosis.  From  my  own 
esperience  I  cannot  state  with  certainty  but  it 
seems  possible  that  the  pains  in  the  feet  observed 
in  typhoid  fever  are  due  to  a  similar  cause,  if  not 
more  correctly  to  neuralgic  influences. 

Dysbasia  angiosclerotica  with  symptoms  sim- 
ilar to  those  here  discussed  may  be  observed  in 
inveterate  cigarette  smokers. 

In  metatarsalgia,  i.e.,  Morton's  disease,  a  pe- 
culiar kind  of  pain  in  the  feet  occurs.  It  is 
centered  in  the  metatarso-phalangeal  joint, 
mostly  of  the  4.  toe,  radiates  upwards  and  be- 
comes so  distressing  in  walking  (narrow  shoes 
the  likely  cause!)  that  the  patient  must  stand 
still  and  rest.  When  the  footwear  has  been 
removed  and  the  painful  parts  are  massaged, 
the  pains  generally  disappear.  Local  reddening 
and  swelling  are  seldom  observed  and  I  am  not 
prepared  to  state  in  how  far  anatomical  changes 
in  the  joint,  or  anomalies  in  the  fascia  or  pressure 
on  the  ramus  communicans  by  the  head  of  the  4. 
metatarsus  are  the  responsible  factors.  But  I 
think  that  X-ray  examinations  should  be  made 
freely.  If  gout  be  the  irritating  cause  it  will 
be  shown  by  local  reddening  and  swelling.  The 
differentiation  from  pes  planus  lies  in  the  narrow 
limitation  of  the  pains;  and  the  presence  of 
pulsation  in  the  pedal  arteries  separates  it  easily 
from  dysbasia  angiosclerotica. 


EXTREMITIES  345 

When  the  patient  complains  of  pains  in  the 
soles  of  the  feet  whilst  walking  or  standing,  with 
local  tenderness  now  in  the  heel,  then  in  some 
other  part  of  the  sole,  we  must  think  of  neuras- 
thenic and  hysteric  podalgia.  The  diagnosis 
offers  some  difficulties  even  if  we  observe  signs 
of  neurasthenia  and  hysteria  and  no  possible 
anatomic  causes  can  be  found.  At  times  it  is 
made  positive  only  when  the  pains  suddenly 
vanish. 

But  if  the  pains  are  vague  in  character  and 
cannot  be  localized  with  ease,  neurasthenia  is 
the  most  likely  causal  factor.  However,  in  neu- 
rasthenia the  pains  in  the  extremities  are  very 
rarely  of  great  intensity.  As  a  rule,  the  patient 
complains  chiefly  of  headache,  pains  in  the  small 
of  the  back  and  in  the  chest,  but  rather  of  a 
painful  feeling  of  fatigue  in  the  limbs,  burning 
neurasthenic  dysbasia  and  podalgia.  But  what 
I  consider  the  distinguishing  features  of  this 
painful  weariness,  consists  in  the  fact  that  the 
patient  feels  more  jaded  in  the  morning  than 
at  eventide,  broken  up,  so  to  speak,  all  over  the 
body,  that  the  pains  are  not  sharpened  by  local 
pressure,  that  they  eventually  are  mitigated  by 
moderate  physical  and  mental  activity  (a  nice 
walk  in  the  open  air),  that  we  cannot  find  an 
essential  reduction  of  the  rude  motoric  power, 
though  the  patient  tires  out  much  quicker,  and 
finally  that  we  can  always  discover  the  typical 


346  GENERALIZED   PAIN 

neurasthenic  stigmata,  foremost  among  them 
abnormal  psychic  and  mental  conditions. 

In  nicotinism  and  a  good  many  diseases  of 
the  internal  secretory  glands  (Addison's  disease, 
myxedema)  pains  in  the  extremities  are  linked 
with  initial  symptoms. 

A  similar  painful  sensation  in  the  muscles  of 
the  extremities  is  often  experienced  by  epileptics 
in  the  stadium  between  the  fits,  but  then  these 
unfortunates  suffer  from  all  kinds  of  neuras- 
thenic symptoms  during  that  period. 

In  hysteria  (traumatic  hysteria  as  well)  the 
incessant  complaint  of  pain  is  the  ground  pillar 
of  the  symptomatic  structure.  So  far  as  the 
extremities  are  concerned,  we  must  distinguish 
between  two  subdivisions,  viz.,  tropalgia  to  which 
arthralgia  and  pains  in  the  periosteum  belong 
(cf.  chapters  on  "Articular  Pain"  and  "Pains 
in  the  Bones"),  and  secondly  neuralgiform  pains, 
rether  rare,  however.  The  diagnosis  takes  root 
in  the  fact  that  these  pains  are  attended  by  dis- 
tinct cutaneous  hyperesthesia  of  a  circulary 
character  and  nearly  always  by  pains  in  other 
parts  of  the  anatomy,  e.g.,  in  the  mammas,  pit 
of  the  stomach  or  in  the  back  and  also  by  the 
other  manifestations  of  hysteria. 

In  pulmonary  emphysema  the  patient  always 
suffers  from  "rheumatic"  pains  in  the  leg  near 
the  ankle-joint.  In  some  instances  there  is  no 
apparent  connection  between  these  pains  and  the 


EXTREMITIES  347 

existing  emphysema,  for  instance,  in  a  case  of 
concurrent  alcoholism,  when  a  closer  examina- 
tion divulges  alcoholic  neuritis.  In  other  patients 
the  pain  rests  in  the  bones,  especially  in  the 
tibia  above  the  knuckle  with  strongly  localized 
tenderness.  It  is  a  sort  of  miniature  edition  of 
osteoarthropathie  pneumique  caused  by  chronic 
bronchitis  and  dilatation  of  the  bronchi,  so  com- 
mon in  emphysema. 

If  we  find  dragging  pains  in  the  extremities 
and  the  patient  cannot  tell  whether  they  are  in 
the  bones,  muscles  or  joints  we  must  think  of 
"growing  pains"  in  youthful  individuals.  If 
there  are  no  traces  of  organic  defects  the  diag- 
nosis is  patent,  even  if  dyspeptic  troubles  and 
slightly  febrile  conditions  might  tempt  us  to 
think  of  another  disease. 

I  append  here  a  diagnostic  observation  of 
some  value.  We  come  across  patients  some- 
times who  cannot  localize  a  pain  in  the  leg  which 
comes  on  after  standing  or  walking  for  some 
time,  possibly  due  to  overtaxing  the  limb.  It  is 
advisable  in  such  cases  to  make  a  careful  search 
for  a  morbid  process  in  the  contralateral  extrem- 
ity. We  may  find  muscular  atrophy  or  an  ab- 
normal shortening  of  this  extremity.  Likewise 
examine  the  spine  for  deformities  or  other  de- 
fects. The  cause  may  also  lie  in  occupational 
overexertion. 

Extraordinary  forced  marches  reveal  many 


348  GENERALIZED 

such  cases  among  troops.  The  tibia,  the  peri- 
ostium  and  the  processes  of  the  muscles  are  here 
the  seat  of  the  pains.  We  find  similar  condi- 
tions in  porters  who  carry  heavy  loads,  and  in 
very  fat  people. 

Among  the  various  pains  in  the  extremities 
those  in  the  bones  receive,  as  a  rule,  the  least 
attention,  especially  when  they  are  of  an  un- 
steady nature,  are  changeable  as  to  time  and 
localization,  and  morbid  changes  in  the  bones 
which  are  not  palpable.  I  refer  the  reader  to 
the  different  chapters  on  "Pains  in  the  Bones, 
Muscles,  Joints." 

Of  course,  it  goes  without  saying  that  pains 
in  the  extremities  may  be  due  to  several  parallel 
causes.  I  have  seen  cases  in  which  arthritis 
deformans  coxse  dextrse,  ischias,  pes  planus  and 
varicose  veins  were  all  bunched  together  in  one 
and  the  same  carrier. 

In  some  rare  cases  pains  in  bilateral  extremi- 
ties may  derive  their  origin  from  a  bilateral 
cerebral  lesion.  Just  the  same  they  may  also 
proceed  from  a  single  morbid  focus,  e.g.,  a 
tumor  in  the  pons  may  provoke  paresthesia  (also 
anesthesia)  in  the  extremities  on  both  sides  of 
the  body,  and  corresponding  pains,  too;  or  else 
in  the  arms  only  or  in  the  legs  or  in  three  extrem- 
ities with  analogous  disturbances  in  both  sides 
of  the  face. 

A  special  subspecies  of  pains  in  the  extremi- 


EXTREMITIES  349 

ties,  mostly  bilateral,  are  the  so-called  lancinat- 
ing pains.  They  are  intermittent  in  character, 
come  on  very  suddenly,  and  penetrate  the  deeper 
muscles  like  a  shot.  The  patient  generally 
speaks  of  them  as  very  severe  rheumatic  pains. 
At  times  they  arrive  in  the  form  of  a  shock, 
moving  the  affected  limb  with  an  abrupt  con- 
vulsive jerk.  When  this  happens  we  should 
look  for  some  lesion  of  the  spinal  nerve-roots, 
but  if  the  pains  recur  with  unusual  frequency 
they  are  a  possible  warning  of  tabes  dorsalis. 
Look  for  divers  missing  or  diminished  patellar 
with  increased  abdominal  reflexes,  absence  of 
achilles  tendon  and  triceps  reflexes.  We  shall 
very  likely  find  abnormally  small  pupils  which 
are  painful  under  the  influence  of  light,  constant 
accommodation  and  convergence  reaction,  Barn- 
berg's  phenomenon  and  disturbances  of  super- 
ficial and  deep  sensibility.  From  the  observance 
of  ataxia,  of  bladder  and  rectal  disorders,  changes 
in  the  innervation  of  the  exterior  ophthalmic 
muscles,  and  in  the  fundus  of  the  eye,  together 
with  the  aforesaid  symptoms,  the  proper  diag- 
nosis will  easily  crystalize.  When  the  lancinat- 
ing pains  are  the  first  apparent  sign  of  the  dis- 
ease the  situation  may  be  more  intricate.  A 
thorough  probing  for  ataxia  in  the  lower  extrem- 
ities is  then  indicated  (especially  in  athletes, 
tourists,  and  persons  who  are  given  to  violent 
bodily  exercise).  The  tendon  reflexes  should 


350  GENERALIZED   PAIN 

receive  careful  consideration  and  also  the  ques- 
tion of  previous  syphilitic  infection.  Globulin 
reaction,  lymphocytosis  of  the  cerebrospinal  fluid 
and  the  Wassermann  reaction  are  further  adju- 
vants in  the  diagnosis. 

Errors  are,  perhaps,  more  frequent  when  these 
lancinating  pains  enter  the  arms  or  only  one 
arm  at  a  time.  Still,  the  symptoms  described 
just  now  should  suffice  to  promptly  establish 
the  existence  of  a  superior  or  cervical  tabes. 

However,  not  only  tabes  or  taboparalysis,  but 
all  encroaching  diseases  of  the  vertebras  and  their 
marrow,  are  apt  to  irritate  the  intraspinal  nerve 
roots  to  such  an  extent  that  lancinating  pains 
are  the  result.  In  gout,  a  deposit  of  urates  in 
the  dura  mater  and  in  the  nerve  roots  indubitably 
has  this  effect. 

All  morbid  intraspinal  processes,  such  as  syr- 
ingomyelia,  myelitis,  multiple  sclerosis,  tumors 
of  the  spinal  cord  as  well  as  peripheral  forms  of 
neuritis,  are  possible  causes  of  lancinating  pains. 
Apparently  few  mistakes  occur  in  the  diagnosis 
when  the  lower  extremities  are  concerned.  But 
I  must  admit  that  when  the  arms  are  attacked 
by  these  lancinating  pains,  the  diagnosis  gener- 
ally goes  wrong,  i.e.,  in  the  direction  of  rheu- 
matism, gout,  neuralgia,  etc.  The  obvious  rea- 
son is  that  this  form  of  pain  is  affected  in  a 
similar  fashion,  as  in  rheumatism  by  weather 
conditions,  thermic  influences,  and  sudden 


EXTREMITIES  351 

changes  in  the  atmospheric  temperature.  The 
diagnosis  should  be  made  from  the  most  care- 
ful consideration  of  the  characteristic  tabetic 
signs,  especially  in  the  eyes,  and  proper  thought 
must  be  given  to  other  diseases  that  are  likely 
to  affect  the  spinal  cord.  I  have  seen  quite  a 
number  of  cases  of  multiple  insular  sclerosis  in 
which  neuralgiform,  lancinating  pains  in  the 
upper  extremities  endured  for  years;  in  fact, 
were  the  sole  perceptible  morbid  symptom.  In- 
tention tremor,  irregularities  in  the  vocal  mech- 
anism, BabinsWs  toe  phenomenon,  abdominal 
wall  reflexes  missing  on  one  side  and  increased 
tendon  and  periosteal  reflexes  should  be  decided 
aids  in  diagnosing  such  cases  generally  observed 
in  persons  of  youthful  age. 

In  caisson  diseases,  lancinating  pains  in  the 
extremities  are  prominent  among  the  initial 
symptoms. 

They  are  likewise  the  most  significant  con- 
comitant manifestation  of  peripheral  neuritis. 
In  diabetes  mellitus  they  appear  in  the  lower  as 
well  as  in  the  upper  extremities,  and  prevail 
likewise  in  nicotinism. 

It  is  these  lancinating  pains,  combined  with 
missing  patellar  reflexes,  eventual  ataxia  and 
paralysis  of  the  eye  muscles  which  make  diabetes 
mellitus  resemble  tabes  dorsalis  in  so  many  cases 
when  glycosuria  attends  the  latter. 

Lumbar  puncture  is  an  important  factor  here. 


352  GENEBALIZED   PAIN 

Of  course,  we  must  not  forget  that  both  diseases 
may  also  exist  alongside  of  each  other.  But 
there  is  one  point  which  does  not  seem  to  have 
received  adequate  attention  in  medical  circles.  I 
mean  the  fact  that  lancinating  pains  of  great 
intensity  in  the  extremities,  combined  with  anal- 
ogous shooting  pains  in  the  breech  and  in  the 
chest,  are  not  uncommonly  a  warning  sign  of 
an  impending  coma  in  diabetes,  despite  the  fact 
that  the  patient  has  not  previously  experienced 
similar,  not  even  neuritic  (neuralgic)  pains. 

Peripheral  pseudotabes,  i.e.,  chronic  alcohol- 
ism, ergotism  and  other  intoxications,  are  like- 
wise associated  with  lancinating  pains  in  the 
extremities.  To  this  list  must  be  added  aneu- 
rysm  of  the  abdominal  aorta,  abdominal  and  pel- 
vic and  intraspinal  tumors,  especially  when  the 
pains  occupy  only  one  side  of  the  body.  Never- 
theless, there  are  cases  of  tabes  dorsalis  on  rec- 
ord in  which  continuous  unilateral  lancinating 
pains  were  observed. 

In  acromegaly,  in  hypophysis  tumors,  they  are 
initial  symptoms.  Owing  to  their  neuralgiform 
character,  to  the  loss  of  vision,  to  diminished  or 
wanting  patellar  reflexes,  the  erroneous  diagno- 
sis of  tabes  dorsalis  or  progressive  paralysis  is 
apt  to  be  made.  It  is  probable  that  a  secondary 
degeneration  of  the  posterior  column  of  the 
spinal  cord  is  the  causative  factor  of  these  mani- 
festations. The  usual  symptoms  of  acromegaly 


EXTREMITIES  353 

should  govern  the  diagnosis  in  that  direction. 
Polyuria,  signs  of  adipose  genital  degeneration, 
hemianopsia  and  hypophyseal  tumors  are  possi- 
bilities to  be  reckoned  with.  The  X-ray  offers 
good  opportunities. 

Exceptionally,  tumors  of  the  brain  exercise 
an  irritating  influence  on  the  cerebro-sensible 
centers,  e.g.,  in  the  thalamus  opticus,  especially 
in  the  pulvinar.  I  have  in  mind  a  tumor  of  the 
perineal  body.  Lancinating  pains  in  these  af- 
fections are  common. 

Tome  spastic  conditions  in  the  muscles  are 
correlated  with  pains  in  the  extremities,  and  may 
be  part  of  the  symptoms  of  intermittent  dys- 
pragia,  as  they  are  the  essential  element  of  occu- 
pational cramps. 

Muscular  cramps,  especially  in  the  calves 
during  walking,  belong  to  polyneuritis,  unless 
they  are  caused  by  muscular  sural  rheumatism. 
The  diagnosis  of  all  these  affections  should 
easily  result  from  the  pertinent  typical  symp- 
toms described  in  other  pages  of  this  book.  I 
include  here  also  all  forms  of  tetany  comprising 
hysterical  pseudotetany . 

When  we  encounter  painful  muscular  cramps 
which  resemble  tetany  we  must  look  for  some 
anatomical  lesion,  primarily  tetanus.  Here  we 
may  find  at  first  only  twitchings  and  muscular 
spasms  (aura  tetanica)  in  the  extremities  which 
are  strictly  localized  and  associated  with  drag- 


354  GENERALIZED   PAIN 

ging  or  tearing,  sudden,  violent  pains.  The  dif- 
ferentiation between  convulsions  in  tetanus  and 
tetany  is  based  upon  the  fact  that  in  tetanus 
the  cramps  affect  principally  the  masseter  (slight 
degrees  of  trismus!),  also  the  nuchal  muscles 
opisthotonus),  which  is  not  the  case  in  tetany; 
further,  that  tetanus  is  caused  by  a  wound  which 
in  many  cases  has  been  overlooked  by  the  pa- 
tient, not  to  speak  of  tetanus  infections  in  the 
uterine  cavity,  in  the  air  passages  or  in  the  in- 
testines. Moreover,  in  tetanus  the  characteristic 
generalized  muscular  spasms  and  other  typical 
signs  (fever,  although  not  uncommon  also  in 
tetany,  heavy  perspiration,  eosinophilia  of  the 
blood)  soon  manifest  themselves. 

There  are,  however,  certain  rudimentary  forms 
of  tetanus  in  which  a  painful  spastic  stiffening 
of  the  muscles  is  the  only  perceptible  symptom. 

If  we  fail  to  find  the  cause  for  the  tetanus 
infection  (men  working  in  the  soil  or  stable,  or 
wound  in  the  body),  if  the  animal  test  with  the 
blood,  fecal  matter  or  bronchial  secretion  of  the 
patient  yields  negative  results,  the  diagnosis  may 
be  hard  to  make,  and  we  may  have  to  fall  back 
upon  other  means  for  assistance. 

There  is  a  third  form  of  painful  muscular 
spasms  in  tetanus  which  must  be  mentioned  here, 
i.e.,  they  are  definitely  and  permanently  confined 
to  an  individual  area  of  the  body,  mainly  to  one 


EXTREMITIES  355 

of  the  extremities,  and  thus  constitute  the  car- 
dinal symptom  of  "local  tetanus." 

Painful  muscular  spasms  resembling  tetany 
are  likewise  found  in  a  large  number  of  exoge- 
nous, acute  intoxications,  and  are  always  com- 
bined with  other  cerebral  symptoms  (arsenic, 
phosphorus,  saltpeter,  filix  mas,  etc.,  poisonings). 
The  differential  diagnosis  is  self-evident,  and 
need  not  be  discussed  here. 

Nocturnal  cramps  in  the  calves,  in  the  soles 
of  the  feet  and  in  the  abductor  hallucis  concern 
the  physician  only  from  the  etiologic  standpoint. 

A  sudden  attack  of  unilateral  cramps  in  the 
calf  may  be  the  result  of  a  muscular  rupture; 
if  recurrent,  due  to  an  induration  in  the  muscles 
as  a  sequel  of  the  primary  rupture. 

The  causes  for  these  spasms  are  either  local 
or  general.  Nocturnal  bilateral  cramps  call  for 
urinary  analysis.  They  may  be  symptomatic  of 
diabetes  mellitus  or  of  uremia.  In  gout,  they 
are  accompanying  symptoms  sounding  a  warn- 
ing note  of  an  impending  severe  painful  attack, 
or  they  act  as  an  expression  of  chronic  diathesis. 
Cramps  in  other  muscles,  e.g.,  of  the  thigh,  arm, 
back  or  abdomen,  often  attend  the  sural  spasms 
in  gout.  I  have  spoken  of  the  presence  of 
uratic  crystals,  hyperuricemia  and  uricemia,  etc., 
in  connection  with  this  disease  in  another  place 
to  which  I  refer  the  reader. 

Ectogenous  poisons    (alcohol),   abuse  of  to- 


356  GENERALIZED   PAIN 

bacco  and  physical  overexertion  (late  hours)  are 
other  exciting  factors,  to  which  may  be  added 
gastralgia,  cold,  wet  feet  and  spastic  constipa- 
tion, affections  of  the  peripheral  nerves,  of  the 
pyramidal  tracts  (multiple  sclerosis,  spastic 
spinal  paralysis). 

Anhydremia  is  often  attended  with  muscular 
pains  in  the  upper  extremities — a  valuable  symp- 
tom in  asiatic  cholera  and  cholera  nostras.  These 
cramps  in  the  calves  are  also  observed  in  other 
diseases  which  run  a  course  similar  to  cholera, 
such  as  paratyphoid,  dysentery,  malaria  or  fun- 
gus poisoning. 

In  gastrosuccorhea  they  come  in  with  the 
periodical  gastric  attacks,  but  whether  they  are 
due  here  to  toxic  influences  or  to  abnormal  thick- 
ening of  the  blood  is  questionable.  There  are  a 
good  many  other  toxic  conditions  which  assume 
the  character  of  cholera  and  in  which  tonic 
spasms  radiate  from  the  sural  region  over  the 
whole  muscular  system,  such  as  arsenic,  chrome, 
saltpeter,  ptomain  poisoning,  and  botulism. 

Painful  cramps  in  the  calves  are  also  due  to 
flat  foot  and  osteomalacia,  to  defective  circula- 
tion in  the  veins,  e.g.,  phlebectasia,  phlebitis  and 
phlebothrombosis.  They  also  originate  from 
ischias  or  polyneuritis,  or  constitute  the  solitary 
symptom  of  an  initial  compression  of  the  ischia- 
dic  nerve.  Perhaps  this,  as  well  as  congested 


EXTREMITIES  357 

circulation,  are  the  provocative  element  of 
cramps  in  the  calves  of  pregnant  women. 

Sometimes  they  are  caused  by  stretching  the 
feet,  and  may  then  be  a  sign  of  latent  tetany  or 
an  accompanying  symptom  of  tabetic  crises  in 
the  extremities.  But  they  may  also  be  directly 
due  to  a  disease  of  the  sural  muscles,  for  in- 
stance to  a  cysticercus  or  to  trichinae.  If  the 
former  is  calcified,  the  Roentgen  picture  will 
show  its  presence.  Subacute  and  subchronic 
periarteritis  nodosa  must  be  mentioned  also. 

If  in  perfectly  normal  and  healthy  persons 
these  cramps  are  sometimes  observed,  we  shall 
very  likely  find  that  they  are  due  to  overexer- 
tion  or  overfatigue,  e.g.,  after  a  long  march  or 
walk,  climbing  high  stairs  or  mountains,  riding 
on  horseback,  athletic  exercises  etc.  The  diag- 
nosis should  offer  no  difficulty. 

The  so-called  cramp  neurosis  gives  rise  to  such 
pains  in  the  calves.  I  have  had  no  opportunity 
to  observe  cases  of  this  kind  but  it  seems  to  me 
that  the  only  causative  element  is  a  peculiar 
predisposition  to  this  ailment. 

A  retrospect  of  the  foregoing  pages  will  tell 
us  that  pains  and  paresthesias  in  the  extremities 
are  to  a  great  extent  manifestations  of  the  same 
diseases;  the  paresthesias,  in  fact,  often  fore- 
runners, if  not  substitutes  of  the  pains.  We 
also  have  learned  that  these  pains  may  have  a 
totally  different  meaning  in  one  and  the  same 


358  GENERALIZED   PAIN 

disease.  For  instance,  when  the  patient  com- 
plains of  such  pains  during  or  after  an  attack 
an  acute  infection,  especially  during  the  puer- 
peral stage,  the  differential  diagnosis  revolves 
around  phlebitis  and  acute  neuritis.  Muscular 
tenderness  is  common  to  both,  but  tenderness  in 
the  nerve  trunks,  subjective  paresthesias,  sub- 
jective and  objective  sensibility  disorders,  pri- 
marily increased,  later  diminished,  tendon  re- 
flexes, temporary  muscular  paresis,  palpable 
nodes  in  the  nerve  trunks,  assure  us  of  neuritis, 
whilst  infectious  or  post-infectious  phlebitis  is 
clearly  indicated  when  the  veins  feel  like  cords 
and  cyanosis  and  edema  of  the  skin  are  found 
in  the  region  along  the  whole  venous  trunkline. 


I  wish  to  say  something  here  about  a  mistake 
which  I  made  once,  at  any  rate  for  several  hours. 
In  a  case  that  was  brought  to  me,  I  diagnosed 
acute  hysteria,  whilst  in  reality  it  turned  out  to 
be  acute  thrombophlebitis  of  one  of  the  lower 
extremities,  with  resultant  hysterical  conditions. 
My  diagnosis  would  have  been  more  reserved, 
if  not  correct,  had  I  given  more  mature  thought 
to  the  fact  that  every  form  of  anatomical  dis- 
ease in  an  hysterical  individual  is  apt  to  awaken 
a  slumbering  neuritis. 

Before  I  conclude  this  chapter,  I  wish  to 
state  that  flat  foot  may  also  be  the  cause  of 
local  pain  in  the  foot  itself.  I  mention  it  be- 


EXTREMITIES  359 

cause  it  has  been  my  experience  that  it  is  very 
frequently  overlooked  in  the  diagnosis.  I  have 
in  a  previous  place  stated  that  pains  caused  by 
pes  planus  generally  disappear  when  the  feet 
are  resting,  but  this  is  only  the  case  when  there 
are  no  local  inflammatory  conditions  which  so 
frequently  affect  the  ankle  joint. 

It  is  not  uncommon  that  persons  with  flat 
feet  complain  of  painful  muscular  cramps  in  the 
soles  of  the  feet  after  standing  for  a  longer 
time,  which  also  appear  in  the  plantar  flexions 
of  the  toes,  attended  with  local  paresthesias. 
Perhaps  a  secondary  neuritis  of  the  plantar 
nerve  is  at  fault  here. 

A  long  list  of  morbid  processes  in  the  feet 
and  hands  which  leads  to  local  pains  belongs  in 
the  field  of  surgery.  I  refer  to  luxations,  sub- 
luxations,  caries,  etc.,  etc.  But  I  think  it  proper 
to  mention  Morton's  disease  and  also  the  fact 
that  there  is  an  individual  form  of  neuritis  of 
the  hands  and  feet.  A  careful  examination  of 
the  fascia  and  ligaments  should  always  be  made 
when  a  patient  complains  of  pains  in  the  soles 
of  the  feet,  particularly  so  after  the  attack  of 
an  infectious  disease  such  as  influenza,  typhoid, 
etc.,  because  in  such  cases  the  irritating  cause  is 
frequently  to  be  found  in  neuritis,  plantar  phle- 
bitis, fasciitis  or  ostitis.  Pains  in  the  heel  or  in 
the  knee  are  often  due  to  neuritic  affections  of 
the  ischiadic  nerve  (ischias). 


360  GENERALIZED   PAIN 

Inflammations  or  new  growths  in  the  tendon 
sheaths  or  in  the  synovial  sacs  are  likewise  possi- 
bilities not  to  be  neglected.  They  are  often 
enough,  especially  when  symmetical  in  form,  the 
result  of  articular  rheumatism,  syphilis,  tuber- 
culosis, pyemia,  scarlatina  or  smallpox.  I  re- 
member a  case  of  multiple  almost  perfectly 
symmetrical  hygroma  combined  with  chronic 
articular  rheumatism  which  was  the  effect  of 
diphtheria.  Tendovaginitis  and  hygroma  are 
not  only  congenital  diseases,  but  just  as  often 
the  manifestation  of  some  gouty  affection  or  of 
hydrops  hypostrophos. 

In  conclusion,  a  word  about  pains  in  the  arm- 
pit or  in  the  groin.  They  arise  from  some 
primary  disease,  unless  they  are  merely  irradia- 
tions of  a  morbid  condition  in  the  nerve  trunk. 
Pains  in  the  groin  point  to  the  appendix  or 
some  disease  of  the  cecum  (if  on  the  left  side 
they  direct  our  attention  to  the  sigmoid  flexure) ; 
in  fact,  to  any  organ  in  the  pelvic  cavity.  I 
name  retroperitoneal  muscular  hematoma  due 
to  hemophilia.  Affections  of  the  male  genital 
organs,  particularly  of  the  spermadic  cord,  of 
the  testicles  or  of  the  epididymis,  are  possibilities 
here  which  we  should  ever  bear  in  mind.  Al- 
though they  belong  mainly  in  the  province  of 
surgery,  they  concern  the  internist  equally  as 
well.  I  have  a  case  of  pendulous  abdomen  in 
mind  which  came  under  my  observation.  It 


EXTREMITIES  361 

caused  the  patient  (female,  otherwise  not  abnor- 
mally stout)  very  severe  pains  in  the  groins. 
Dietetic  and  balneotherapeutic  measures  and  a 
properly  adjusted  corset  removed  the  cause  of 
the  pains  in  a  comparatively  short  time. 


Muscular  Pains 

Muscular  affections  are  generally  indicated 
when  the  patient  complains  of  pains  in  the 
"fleshy"  parts  of  the  body.  By  rolling  and 
pressing  the  muscles  in  the  affected  part  be- 
tween the  fingers  we  should  be  able  to  find  local 
tenderness,  and  thus  localize  the  pain,  unless 
functional  conditions  (cramps)  or  morbid 
changes  in  the  tissue  itself  (indurations,  nodes, 
infiltrations,  cords)  have  already  furnished  the 
necessary  information.  But  it  is  well  to  bear  in 
mind  that  sensitiveness  on  pressure  in  a  certain 
muscle  or  in  a  complex  of  muscles  is  by  no 
means  always  a  definite  proof  of  a  muscular 
affection,  because  it  may  just  as  well  be  due 
to  a  morbid  process  in  the  intramuscular  nerves 
or  veins,  or  to  a  complication  such  as  neuro- 
myositis. 

Where  muscular  pain  exists  the  differential 
diagnosis  revolves  around  the  question  whether 
it  is  due  to  a  primary  affection  of  the  muscles 
themselves  or  to  intramuscular  neuritis  or  to  a 
disease  of  the  muscular  veins  (neuritis,  phlebitis, 
phlebothrombosis,  phlebosclerosis) . 

In  intramuscular  neuritis  the  muscles  are  de- 
cidedly sensitive  on  pressure,  and  the  diagnosis 

862 


MUSCLES  363 

must  be  based  on  other  symptoms.  In  some  of 
these  cases  the  nerve  trunks  are  also  very  sensi- 
tive and  show  localized  swellings  (nodes).  We 
also  find  paresthesia  or  sensibility  disturbances, 
abnormal  tendon  reflexes  or  trophic  disorders  of 
the  skin,  epithelial  formations,  if  not  muscular 
convulsions.  All  these  symptoms  are  calculated 
to  harden  the  diagnosis  of  neuritis.  The  anam- 
nesis is  also  likely  to  reveal  certain  etiologic 
factors  (intoxications,  e.g.,  arsenic  or  a  preced- 
ing infectious  disease)  or  some  concomitant 
manifestation  of  the  disease  (a  weak  heart,  an 
edema  in  beri-beri). 

On  the  other  hand,  there  are  cases  of  neuritis 
in  which  only  the  muscular  branches  of  the 
nerves  are  apparently  affected.  Whilst  all  other 
neuritic  symptoms  are  missing,  we  only  find 
local  pain  and  tenderness.  Here  a  differentia- 
tion between  true  muscular  and  intramuscular 
nervous  diseases  is  simply  impossible,  at  any  rate 
in  the  initial  stages.  This  explains  the  reason 
why  some  very  eminent  authorities — the  leading 
figure  among  them  is  A.  Schmitt — look  upon 
so-called  muscular  rheumatism  primarily  as  a 
disease  of  the  branches  of  the  muscular  nerves; 
in  other  words,  they  consider  rheumatic  myalgia 
to  be  neuralgia. 

Where  complaint  is  made  of  pains  which  have 
persisted  for  some  time  in  the  lower  extremities, 
particularly  where  the  muscles  of  the  calves  are 


364  GENEKALIZED   PAIN 

sensitive  on  pressure,  we  might  attribute  these 
conditions  to  phlebosclerosis  resp.  to  phlebectasia 
of  the  muscular  branches  of  the  veins.  The 
existence  of  ectasy  of  the  superficial  cutaneous 
veins  (trunks  as  well  as  branches),  the  presence 
in  the  evening  of  edema  in  the  knuckles  and 
increased  pain  when  the  patient  stands  on  his 
feet  for  some  time  will  help  greatly  to  make 
the  diagnosis  concrete. 

But  when  such  pains  suddenly  arrive  chiefly 
in  the  muscles  of  the  calves,  we  should  think  of 
intramuscular  phlebitis  resp.  thrombophlebitis. 
If,  then,  manifestations  of  phlebitis  of  the  cuta- 
neous veins  or  of  the  trunks  of  the  veins  accede, 
the  diagnosis  becomes  self-evident.  If,  however, 
such  an  exclusively  intramuscular  phlebitis  con- 
tinues to  exist  by  itself,  the  diagnosis  is  re- 
stricted solely  to  subjective  pains  and  objective 
sensitiveness.  It  will  gain,  however,  by  the 
anamnesis,  for  we  know  that  intramuscular 
phlebitis  is  the  commonest  sequel  of  a  long- 
continued  infection,  more  rarely  of  intoxications. 

When,  however,  the  two  aforesaid  etiologic 
factors  are  wanting  and  pain  in  the  muscles  is 
coupled  with  local  sensitiveness,  we  are  justified 
in  looking  upon  the  muscular  system  as  the 
place  of  origin  of  such  pains.  We  then  have 
two  alternatives  before  us,  viz.:  the  affection  is 
either  purely  local  so  far  as  place  and  time  are 
concerned,  or  we  are  dealing  with  a  morbid 


MUSCLES  365 

condition  which  involves  multiple  muscular 
groups  or  an  extensive  area  of  the  muscles  of 
the  body.  In  both  cases  the  pains  are  either 
acute  and  of  a  short  duration,  or  they  have  ex- 
isted already  for  some  time. 

I.  Locally  Limited  Unilocular 
Muscular  Pain 

Most  of  the  details  concerning  this  subject  are 
contained  in  other  chapters  of  this  volume,  as 
well  as  in  Volume  I,  "Abdominal  Pain."  I  will, 
however,  repeat  collectively  this  much.  When 
a  patient  complains  of  pains  in  a  restricted  or 
even  rather  extended  muscular  area  and  we  are 
satisfied  that  it  is  a  case  of  myalgia,  we  must 
not  look  for  sensitiveness  in  the  whole  area.  It 
may  be  present  only  in  a  limited  part  of  one 
muscle,  especially  in  its  processes,  and,  again,  it 
may  only  react  under  the  influence  of  the  elec- 
tric current.  Moreover,  there  are  two  phases  of 
acute  localized  myalgia;  one  is  the  rheumatic 
form — muscular  rheumatism  in  the  erector 
trunci  or  in  the  muscles  of  the  shoulder — the 
other  is  traumatic  myalgia.  In  the  latter  case 
the  painful  condition  is  either  due  to  an  over- 
exertion  of  primarily  normal  muscles  (sport, 
athletic  exercises,  etc.),  or  to  constitutionally 
weak  muscles  which  cannot  stand  any  kind  of 
normal  exercise,  e.g.,  in  anemic  or  physically 
run-down  individuals. 


366  GENERALIZED   PAIN 

Pains  that  are  localized  in  or  restricted  to  one 
extremity  or  part  thereof,  also  painful  muscu- 
lar convulsions,  are  often  the  initial  signs  of 
tetanus,  both  local  and  generalized. 

Chronic  pains  in  a  definite  single  muscle  or  in 
a  certain  group  of  muscles  point  to  the  various 
forms  of  chronic  myositis,  primarily  the  fibrous 
chronic  type,  which  attacks  not  only  the  lower 
extremities,  but  also  independently  the  muscles 
of  the  nape  of  the  neck,  of  the  back  and  of  the 
arms.  The  patient  complains  of  dragging, 
rheumatic  pains;  soon  the  muscles  become  rigid, 
a  tumor-like,  hard  swelling  is  formed  which 
grows  together  with  the  skin  and  the  bones.  Of 
course,  so  long  as  this  union  is  not  formed,  the 
diagnosis  is  easy  to  make  from  the  palpable 
muscular  swelling.  Radioscopy  and  histological 
examination  of  an  excised  piece  of  muscle  will 
help  greatly,  and  also  the  fact  that  in  chronic 
fibrous  myositis  local  sensitiveness  is  not  very 
pronounced. 

Still  easier  is  the  diagnosis  of  localized  myo- 
sitis ossificans  due  to  muscular  overstrain  (horse- 
back riding,  military  exercises).  The  patient 
suffers  from  severe  localized  pains  (in  trauma 
due  to  the  tendency  of  the  original  hematoma 
to  ossify)  provoked  by  the  activation  of  the 
affected  muscles.  After  a  week  or  two  a  hard 
tumor  may  be  felt  similar  to  that  found  in  intra- 
muscular hematoma,  syphiloma  and  osteosar- 


MUSCLES  367 

coma.  The  Roentgen  picture  is  sufficient  for  a 
proper  diagnosis. 

I  implicitly  affirm  that  localized  muscular 
pains  must  ever  remind  us  of  all  possible  neo- 
plastic  (also  echinococcus),  acute  as  well  as 
chronic  inflammatory  (gummatous,  tuberculous 
and  gonorrhoic)  changes  in  the  muscular  system. 
The  differential  diagnosis,  however,  affects  the 
surgeon  more  than  the  internist. 

Not  only  new  growths  in  the  muscles,  but  also 
diseases  of  the  bones,  especially  myeloma,  are 
attended  with  localized,  often  severe  muscular 
pains,  for  which  reason  the  wrong  diagnosis  of 
lumbago  or  muscular  rheumatism  is  an  everyday 
occurrence. 

An  attack  of  sudden  severe  pains  in  a  definite 
group  of  muscles,  if  not  in  multiple  areas,  espe- 
cially when  they  bound  from  one  group  to  an- 
other— without  fever  or,  perhaps,  with  fever  for 
a  day  or  two — indicates  acute  muscular  rheuma- 
tism or  rheumatic  polymyalgia.  It  may  also  be 
the  manifestation  of  an  infectious  disease  the 
character  of  which  has  not  as  yet  come  to  the 
surface,  but  very  likely  due  to  catarrh.  Toxic 
conditions  with  a  possible  secondary  inflamma- 
tion of  the  endocardium  or  of  the  pleura,  of  the 
pericardium  or  myocardium,  are  also  to  be 
considered.  The  affected  muscle  appears  swol- 
len, hypertonic  when  palpated  in  relaxation. 
The  same  may  be  said  of  subacute  or  chronic 


368  GENERALIZED   PAIN 

muscular  rheumatism,  in  which,  however,  certain 
muscular  fascia  feel  to  the  touch  more  like  very 
hard  cords.  We  also  find  at  the  deeper  inser- 
tion of  the  muscles  nodules  hard  as  bone  and 
about  the  size  of  a  pea,  which  are  very  painful 
at  times.  In  muscular  rheumatism  the  processes 
of  the  affected  muscles  are  particularly  painful 
on  pressure.  Lifting  the  muscles  and  pressing 
them  between  the  fingers  elicit  exquisite  pain. 
The  patient  feels  the  pains  very  intensely  when 
he  rises  in  the  morning,  but  they  relax  as  he 
gets  about.  They  come  on  all  of  a  sudden 
when  he  sneezes,  stumbles  or  rides  over  a  hard 
road,  etc.,  also  with  a  change  in  the  weather. 
Antirheumatic  drugs  give  generally  desired 
relief. 

Homogeneous  muscular  pains  localized  in  a 
definite  zone  (lumbago,  myalgia  of  the  head  or 
of  the  shoulder  blades  or  neck  and  arms),  also 
when  of  a  shifting  character,  are  often  the  sign 
of  uratic  diathesis.  They  have  no  basic  value  for 
the  differential  diagnosis,  and  we  must  look  for 
other  symptoms.  So  far  as  gout  is  concerned, 
we  may  be  guided  by:  inclination  to  cramps  in 
the  calves,  cutaneous  affections,  itching,  chronic 
eczema,  hemorrhoids,  indigestion,  neuralgic 
pains,  inflammations  of  the  synovial  sacs,  tophi 
(cf.  chapter  on  "Pains  in  the  Chest"),  heredi- 
tary conditions,  personal  habits  (meat-eaters, 
luxurious  living),  examination  of  urine,  retarda- 


MUSCLES  369 

tion  of  the  nuclear  metabolism,  persistent  uri- 
cemia  by  purin-free  diet  and  slow  secretion  of 
uric  acid  after  the  administration  of  nucleinic 
natrium. 

In  diabetes  mellitus  and  in  chronic  alcoholism 
we  find  analogous  shifting  pains.  The  etiologic 
diagnosis  should  offer  no  embarrassment. 

Neurasthenia  is  likewise  the  source  of  vague, 
sometimes  very  intensive  muscular  pains.  We 
find  them  particularly  in  the  chest,  back,  loins 
and  extremities.  The  patient  anticipates  some 
trouble  in  the  lungs,  kidneys,  or  in  the  spinal 
cord.  Local  tenderness  in  the  muscles  and  sen- 
sitive reaction  to  the  electric  current  reveal  the 
seat  of  the  pain. 

Chronic  pains  in  the  muscles  are  nearly  al- 
ways there  in  Addison's  disease.  They  chiefly 
affect  those  in  the  back,  arms  and  legs,  in  the 
shape  of  a  painful  feeling  of  fatigue,  but  when 
the  disease  becomes  more  acute  they  gain  in 
intensity  and  therapeutic  measures  seem  to 
afford  but  little  relief.  Morbid  changes  in  the 
muscles  are  not  in  evidence,  and  electric  reaction 
remains  the  same.  Mechanical  hyperreaction 
in  the  muscles,  painful  or  otherwise,  is  a  definite 
expression  of  Addison's  cachexia.  The  diag- 
nosis can  only  be  made  with  the  aid  of  the  other 
characteristic  symptoms  of  this  classical  disease 
(melanodermia,  adynemia,  low  blood  pressure). 


370  GENERALIZED   PAIN 

Myxedema,  resp.  hypothyreoidism,  is  another 
{disease  of  the  internal  secretory  glands  which 
provokes  sleep-disturbing  muscular  pain.  Be- 
cause pains  in  the  back,  a  feeling  of  cold  and 
abnormal  psychic  and  physical  fatigue,  espe- 
cially in  the  morning,  accompany  this  disease, 
it  is  often  mistaken  for  neurasthenia  or  anemia. 
But  if  we  note  the  bloated  face,  the  swollen 
eyelids,  the  puffed  lips,  the  tendency  to  sub- 
normal temperature,  epilation,  trophic  changes 
in  the  nails,  menstrual  disorders  (amenorrhea, 
menorrhagia),  slight  swellings  in  the  joints,  con- 
stipation and  changes  in  the  psychic  and  physical 
disposition  of  the  patient  (apathy,  sleeplessness, 
sluggishness  of  the  mental  faculties),  we  have 
all  the  diagnostic  facts  before  us. 

In  sporadic  cases  of  Basedow's  disease,  mus- 
cular pains  associated  with  signs  of  severe  myas- 
thenia  have  been  observed.  Whether  an  affec- 
tion of  the  thymus  gland  is  responsible  for  this 
condition  is  questionable. 

There  is  also  a  case  of  tumor  of  the  hypophy- 
sis with  intense  muscular  pains  on  record.  The 
presence  of  the  typical  signs  of  this  disease  may, 
perhaps,  remove  a  possible  doubt,  but  there  is 
still  the  likelihood  that  these  pains  have  their 
genesis  in  another  morbid  endocrine  gland. 

If  slight  pains  have  persisted  in  various  parts 
of  the  musculnr  system,  chronic  lead  poisoning 
may  be  the  irritating  cause.  But  the  clinician 


MUSCLES  371 

must  look  here  for  further  adjuvants,  such  as 
lead  colic,  anemia,  the  blue  line,  articular  pain, 
paralysis  of  the  radialis  and  punctated  red  blood 
corpuscles.  The  pains  are  of  a  vicious,  boring 
and  tearing  nature,  especially  during  the  night- 
time, and  affect  the  joints  and  bones  as  well. 

Subacute  mercury  (sublimate)  poisoning  is 
characterized  by  pains  of  short  duration  in  the 
extremities,  especially  the  legs.  But  I  have  seen 
a  case  in  which  this  intoxication  provoked  ex- 
ceedingly severe  spontaneous  and  pressure  pains. 

If  a  patient  complains  of  acute,  at  first  short- 
lived pains  which  at  the  beginning  are  confined 
to  a  limited  group  of  muscles  but  soon  spread 
to  other  groups,  or  if  from  the  very  start  vari- 
ous zones  of  the  muscular  system  are  involved, 
we  will  have  to  decide  between  acute  polymyo- 
sitis,  neuromyositis  and  dermatomyositis. 

Dermatomyositis  may  be  acute,  subacute  or 
chronic,  and  is  typified  by:  acute  beginning, 
high  fever,  facial  edema,  especially  in  the  eye- 
lids, spontaneous  and  exquisite  pain  on  pressure 
and  on  motation  at  first  in  a  certain  group  of 
muscles,  generally  in  one  side  of  the  calf,  thence 
reaching  over  into  the  contra-lateral  calf,  and 
extending  from  there  into  the  femoral  muscles 
and  even  those  of  the  trunk.  With  every  fresh 
localization  the  general  condition  of  the  patient 
grows  worse  as  new  symptoms  manifest  them- 
selves, such  as  eruptions  of  the  skin  which 


372  GENERALIZED   PAIN 

strongly  resemble  erythematous  conditions,  or 
urticaria,  or  roseola,  or  even  erysipelas.  Later 
on  we  notice  a  hard  edema  in  the  skin  over  the 
affected  muscles  which  does  not  yield  to  pres- 
sure, so  that  the  extremities  look  like  shapeless 
columns,  and  the  face  and  trunk  appear  de- 
formed. When  the  edema  subsides  the  muscles 
remain  strongly  indurated.  Profuse  sweating 
is  common  and  frequent. 

The  muscular  symptoms  of  neuromyositis  are 
a  compound  of  those  belonging  to  dermatomyo- 
sitis  and  multiple  neuritis. 

Acute  hemorrhagic  polymyositis  and  acute 
polymyositis  combined  with  erythema  nodosum 
are  rather  of  rare  occurrence.  Both  have  a 
certain  symptom  complex  in  common,  i.e.,  febrile 
conditions,  the  attack  is  confined  to  the  extremi- 
ties and  manifests  itself  in  local  pains,  local,  at 
times  soft  edema  of  the  skin,  local  swelling  of 
the  muscles  and  painful  muscular  tumor.  The 
muscular  system  of  the  trunk  is  not  affected. 
The  acute  hemorrhagic  form  is  specially  char- 
acterized by  hemorrhages  and  sugillations  of  the 
skin  over  the  affected  muscles,  hemorrhages  in 
the  mucous  membrane  (intestinal  hemorrhages). 
The  other  form  is  typified  by  comph' eating  ery- 
thema nodosum  and  frequently  enough  by  addi- 
tional acute  articular  inflammations. 

These  three  forms  of  polymyositis  are  so 
strongly  marked  that  a  differential  diagnosis  be- 


MUSCLES  373 

tween  them  and  other  diseases  is  rigidly  ex- 
cluded. 

Of  course,  the  matter  assumes  a  different 
aspect  when  acute  or  subacute  dermatomyositis 
is  in  question.  If  the  disease  sets  in  with  fever, 
edema  of  the  eyelids,  forehead  or  temples,  ac- 
companied by  muscular  pains  in  the  extremities 
and  thorax,  which  are  at  times  so  severe  that 
the  patient  lies  motionless,  if  the  muscles  are 
swollen  and  hard,  and  we  find  profuse  perspira- 
tion and  cutaneous  exanthemata  similar  to  those 
of  dermatomyositis,  the  diagnosis  must  be  trichi- 
nosis. A  differentiation  between  these  two  dis- 
eases is  always  necessary  and  can  easily  be  made, 
especially  when  trichinae  are  found  in  the  blood, 
in  the  muscular  tissue  or  in  the  stools,  and  the 
biceps  muscle  is  particularly  affected.  Involve- 
ment of  the  diaphragm  and  of  the  muscles  of 
the  eyes,  jawbones,  and  throat  is  not  ordinarily 
connected  with  acute  dermatomyositis,  but  per- 
haps more  common  than  in  trichinosis. 

In  milder  cases  of  trichinosis,  when  the  pa- 
tient complains  merely  of  general  indisposition, 
unusual  fatigue  and  slight  muscular  pain,  and 
the  rise  in  the  temperature  is  insignificant,  the 
danger  lies  near  to  mistake  the  disease  for  acute 
muscular  rheumatism.  The  same  error  may  be 
made  when  the  symptoms  of  trichinosis  taper 
down  into  a  softer  character  towards  the  end 
of  the  illness. 


374  GENERALIZED   PAIN 

In  recent  years  eosinophilia  has  been  ob- 
served in  muscular  rheumatism,  especially  in 
cases  of  acute  relapse.  A  muscular  induration 
of  old  standing  may  be  the  possible  remainder 
of  a  pristine  invasion  of  trichinae  and  invite  a 
false  diagnosis  of  muscular  rheumatism.  The 
excision  of  a  small  bit  of  muscular  tissue  should 
with  the  aid  of  the  microscope  promptly  correct 
the  error. 

Cysticercus  is  another  parasite  which  pro- 
duces, though  not  of  necessity,  spastic  pains  in 
the  muscles  and  through  pressure  in  the  nerves. 
The  presence  of  the  parasite  in  the  muscular 
tissue  or  else  in  the  fundus  of  the  eye  or  in  the 
brain  is  sufficient  evidence  not  to  speak  of  eosin- 
ophylia  of  the  blood.  Pains  are  rarely  felt  in 
this  disease,  which  may  be  erroneously  taken  for 
a  fibroma. 

The  differentiation  between  polymyositis  and 
purulent  myositis,  which  sets  in  with  localized 
painfulness,  swelling  and  induration  of  a  certain 
muscle,  should  offer  no  difficulties.  The  collat- 
eral edematous  condition  of  the  skin,  with  early 
local  fluctuation,  the  general  symptoms,  state  of 
the  blood  and  evidence  of  suppuration  are  typi- 
cal enough  of  the  nature  of  the  disease. 

It  is  different,  however,  when  the  initial  stages 
of  acute  dermatomyositis  are  localized  in  one 
extremity  only,  e.g.,  in  the  muscles  of  the  calf 
or  some  other  lower  portion  of  the  leg.  A  sud- 


MUSCLES  375 

den  onset  of  fever  and  pain  in  the  extremities, 
local  sensitiveness  and  motoric  inhibition,  local 
edema  of  the  skin  have  misled  many  a  clinician 
into  making  a  diagnosis  of  acute  dermatomyo- 
sitis,  or  acute  myositis,  when  the  patient  was  in 
reality  suffering  from  an  attack  of  thrombo- 
phlebitis of  the  crural  vein.  The  error  would 
not  have  happened  if  more  careful  attention  had 
been  paid  to  the  following  facts:  In  thrombo- 
phlebitis the  edema  shows  an  indentation;  it  does 
not  do  so  in  dermatomyositis ;  in  the  former 
the  patient  perspires  profusely  and  the  edema- 
tous  condition  of  the  skin  does  not  permit  us  to 
palpate  the  thickened,  painful  collateral  ectatic 
veins.  I  will  also  mention  that  thrombophlebitis 
may  also  occur  in  young  people  when  the  sus- 
picion of  acute  syphilitic  myositis  lies  near.  But, 
let  us  remember  that  the  latter  disease  carries 
with  it  pain,  swelling  and  induration  in  the  af- 
fected muscles,  but  is  hardly  ever  attended  with 
edema  of  the  skin;  but  if  it  is,  the  edema  is 
hard  the  same  as  in  ordinary  dermatomyositis. 
Besides,  tentative  specific  treatment  and  the 
complement  fixation  test  should  soon  clear  the 
situation. 

Acute  infectious  diseases  are  a  prolific  source 
of  muscular  pains.  We  may  here  be  dealing  with 
a  true  infectious  myositis  indicated  by  swelling 
and  hardness  of  the  painful  muscles,  e.g.,  the 
rheumatic  or  gonorrhoic  form  of  myositis.  The 


376  GENERALIZED   PAIN 

former  is  either  a  preceding  or  an  accompanying 
manifestation  of  acute  articular  rheumatism,  or 
takes  on  the  form  of  a  subsequent  relapse.  The 
second  form  is  easily  recognised,  being,  as  it  is, 
merely  a  coincidence  of  a  gonorrhoic  articular 
inflammation. 

The  commonest  form  is  acute  pyemic  metas- 
tatic  myositis,  associated  with  many  different 
kinds  of  blood  infection  (myositis  acuta  mal- 
leosa) . 

Purulent  myositis  may  also  supervene  by  con- 
tinuity in  primary  inflammations  of  the  skin  or 
bones. 

Myalgia  is  of  frequent  occurrence  in  the  ma- 
jority of  acute  infections,  and  we  are  strongly 
reminded  here  of  articular  rheumatism  (rheu- 
matic hyalgia). 

Typhoid  fever  belongs  here,  too;  and  we  may 
be  justified  to  use  the  term  "myotyphoid"  in 
this  connection. 

Muscular  pains  are  not  so  unusual  in  para- 
typhoid either.  In  typhoid  fever,  these  pains 
are  often  caused,  in  the  2.  to  4.  week  of  the  dis- 
ease, by  the  waxy  degeneration  of  the  abdominal 
as  well  as  other  muscles — of  the  femoral  adduc- 
tors. The  muscles  feel  soft  like  wax  even  when 
they  are  contracted.  Error  of  peritonitis  is  pos- 
sible here.  (Cf.  "Abdominal  Pain.") 

But  there  is  another  type  of  similar  muscular 
pains  which  often  set  in  at  the  height  of  a  fever. 


MUSCLES  377 

They  attack  by  preference  the  oblique  and 
straight  muscles  of  the  abdomen  and  the  adduc- 
tors, likewise  the  muscles  in  the  back.  We  should 
be  careful  not  to  attribute  these  pains  to  a  waxy, 
but  rather  to  a  toxic  parenchymatous  degenera- 
tion of  the  abdominal  muscles.  From  a  clinical 
standpoint  it  will  be,  perhaps,  difficult  to  make 
a  differentiation. 

Similar  muscular  changes  occur  in  other  acute 
infections  such  as  pneumonia,  sepsis,  pyemia, 
influenza  and  cholera.  But  it  may  be  observed 
that  these  morbid  conditions  are,  as  a  rule,  not 
associated  with  subjective  pain,  but  rather  with  a 
feeling  of  muscular  fatigue  and  local  tenderness. 

Whenever  the  patient  complains  of  vague, 
dragging  pains  in  a  certain  group  of  muscles, 
pains  which  have  a  tendency  to  jump  from  one 
group  to  another,  we  are  safe  to  diagnose  an 
attack  of  chronic  mitigated  sepsis  in  the  oral, 
pharyngeal  cavities  (teeth,  tonsils).  Particulars 
will  be  found  in  "Abdominal  Pain"  and  in  the 
chapter  on  "Nuchal  Pains."  Furthermore,  there 
is  also  a  form  of  mixed  infection  of  sepsis  and 
tetanus.  During  the  World  War  many  such 
cases  were  observed  and  the  opportunity  was 
utilized  to  study  the  genesis  of  this  peculiar 
complication. 

There  are  cases  of  pneumonia — diplococcus 
infection — and  also  sepsis  (pyemia)  in  which  the 
muscular  painfulness  may  be  due  to  a  bacterial 


378  GENERALIZED   PAIN 

invasion  of  the  muscular  arteries,  i.e.,  to  a  true 
acute  embotic  myositis.  Here,  too,  the  sensation 
hardly  ever  passes  beyond  the  stage  of  muscular 
fatigue  or  tenderness. 

In  recurrent  and  in  exanthematous  fever  mus- 
cular pains  are  predominant.  They  are  com- 
bined with  initial  chills,  and  localized  in  the 
calves  and  in  the  margin  of  the  cucullaris,  in  the 
axillary  folds  and  in  the  processes  of  the  sterno- 
cleidomastoid  of  the  sternum.  We  may  look 
upon  them  as  a  characteristic  symptom  caused 
by  a  waxy  degeneration  of  the  muscles. 

In  typical  cases  of  malaria,  especially  tropical, 
intensive  muscular  pains  accompany  every  attack 
of  fever.  We  find  them  in  dorsal  and  lumbar 
muscles  as  well  as  in  those  of  the  extremities. 

During  the  prodromal  stadium  of  the  plague 
severe  muscular  pains  are  experienced  in  the 
nape  of  the  neck  and  shoulders.  And  in  Wol- 
hynian  fever  they  attack  the  calves,  thighs,  del- 
toid, back  and  chest. 

The  influenza  patient  complains  of  very  se- 
vere, tearing  pains  with  exquisite  tenderness  in 
the  swollen  muscles  of  the  thigh,  the  calf,  nape 
of  the  neck  and  back,  particularly  during  the 
night  time.  They  are  not  so  much  due  to  toxic 
influences  but  rather  to  localized  influenzal  myo- 
sitis. The  diagnosis  can  be  easily  made  from 
the  characteristic  symptoms  of  the  disease.  But 
there  is  always  a  possibility  of  post-influenzal 


MUSCLES  379 

myalgia  and  myositis  accompanied  by  muscular 
pains.  Complications  with  other  diseases  such 
as  typhoid,  etc.,  are  not  excluded. 

Pappataci  fever  belongs  to  this  same  category. 
I  have  already  spoken  about  the  diagnosis  of  this 
disease  in  another  place. 

Poliomyelitis  is  apt  to  be  confused  with  articu- 
lar rheumatism  or  influenza.  I  refer  the  reader 
to  the  chapter  on  "Articular  Pains." 

Muscular  and  articular  pains  accompany  yel- 
low fever  in  its  second  stage.  In  epidemics  the 
diagnosis  is  self-evident  nearly  throughout.  But 
in  solitary  cases  it  can  be  made  from  the  initial 
symptoms  of  generalized  infection,  high  fever, 
headache,  lumbar,  muscular  and  articular  pains, 
vomiting,  feeling  of  pressure  in  the  epigastrium, 
hemorrhages  and  icterus. 

In  Weirs  disease  we  find  among  the  earliest 
symptoms  fever,  chills,  vomiting,  diarrhea,  fol- 
lowed by  muscular  pains,  especially  in  the  calves, 
the  nape  of  the  neck,  chest,  abdomen,  sacrum 
and  thighs,  acute  splenic  tumor,  and  within  three 
to  five  days  icterus,  enlargement  of  the  liver, 
acholia  in  the  stools,  nephritis,  delirium,  nose- 
bleed, hemorrhages  of  the  skin  and  mucous  mem- 
branes, herpes  leucocytosis,  polynucleosis  and 
lymphopenia.  The  disease  might  be  taken  for 
infectious  cholangitis  or  typhoid  with  icterus,  but 
the  detection  of  spirochetoe  in  the  blood  should 
soon  correct  any  such  error. 


380  GENERALIZED   PAIN 

Paroxysmal  hemoglobinuria  manifests  itself 
by  chills  and  fever,  high  temperature,  urobilin- 
uria,  hemoglobinuria  and  cylindruria  together 
with  muscular  pains. 

In  chronic  as  well  as  in  acute  cases  of  over- 
fatigue  we  find  pains  in  the  muscles,  sleepless- 
ness, muscular  twitching,  paresthesia,  abnormal 
irritability,  neuralgia,  palpitation  of  the  heart, 
trembling,  burning  sensation  in  the  chest  and  in 
the  extremities. 

In  Weil's  disease  hemorrhages  in  the  muscular 
tissue  cause  local  pains,  and  in  scurvy  pains  in 
the  calves  are  provoked  by  intramuscular  herna- 
tomata. 

Muscular  pains  in  the  loins,  sacrum  and  thigh 
are  initial  symptoms  of  hemoglobinuria  after 
forced  marches  and  other  strenuous  military  or 
athletic  exercises  through  which  the  hemoglobin 
content  of  the  muscles  is  used  up. 

Periarteritis  nodosa  is  a  subacute  or  chronic 
infection  in  which  multiple  muscular  pains  are 
frequently  very  prominent  in  various  areas.  It 
is  sometimes  attended  with  fever  and  paresis  or 
paralysis  of  a  degenerative  character  of  the 
affected  muscles.  Acute  nephritis,  diarrhea  with 
bloody  stools,  profuse  intestinal  hemorrhages  and 
severe  colic  are  other  complications,  likewise 
abdominal  pain,  peritonitis  and  strongly  marked 
cachexia  coupled  with  anemic  conditions.  The 
diagnosis,  however,  can  be  made  positive  only 


MUSCLES  381 

when  we  find  noduliform  swellings  in  the  small 
cutaneous  arteries.  If  syphilis  is  suspected  the 
Wassermann  reaction  may  enlighten  us.  It  is 
advisable  to  think  of  periarteritis  in  all  cases 
which  suggest  the  existence  of  polymyositis  or 
trichinosis. 

Muscular  pains  of  a  minor  degree  or  rather 
an  abnormal  feeling  of  fatigue  in  the  muscles 
frequently  accompany  the  period  of  recovery 
from  an  infectious  disease  of  the  muscles  in  the 
sacrum,  loins  or  extremities,  such  as  smallpox, 
influenza,  erysipelas  and  certain  rudimentary 
forms  of  dysentery. 

Local  or  generalized  muscular  pains  indicate 
also  chronic  infections,  e.g.,  tuberculosis  or  syphi- 
lis, which  are  apt  to  present  pseudoneurasthenic 
conditions  of  a  continuous,  remittent  or  inter- 
mittent character.  They  are  also  forerunners 
of  lactic  exanthema.  The  usual  local  and  gen- 
eralized pertinent  symptoms  are  the  necessary 
requisites  for  a  correct  diagnosis. 

Pains  in  the  muscles  of  the  calves  are  a  com- 
mon early  symptom  of  edematous  diseases.  The 
diagnosis  results  from  abnormal  fatigue,  hypo- 
tonous  bradycardia  and  polyuria  in  addition  to 
the  edematous  conditions. 

In  the  chapters  on  "Pains  in  the  Shoulders" 
and  "in  the  Nape  of  the  Neck"  I  have  pointed 
out  that  pains  which  radiate  particularly  into 
the  muscles  of  the  shoulders  should  remind  us 


382  GENERALIZED   PAIN 

of  some  morbid  process  in  the  lungs,  primarily 
of  tuberculosis,  but  also  of  other  subdiaphrag- 
matic  or  intraperitoneal  affections,  although  as 
a  rule  they  are  not  spontaneous  in  character  but 
rather  elicited  by  local  pressure.  Similar  tender- 
ness in  the  trapezius,  rhomboideus  and  pectoralis 
muscle  is  also  possible  in  dry  pleurisy. 

In  trismus  painfulness  and  rigidity  of  the 
muscles  are  also  perceptible.  An  acute  inflam- 
mation of  the  maxillary  joint  or  of  the  jawbone, 
or  an  articular  stricture  following  an  acute  pain- 
ful affection  of  the  oral  cavity  (wisdom  tooth, 
tongue,  tonsils)  or  of  the  upper  salivary  glands 
at  times  bear  a  strong  resemblance  to  lockjaw 
and  render  the  differential  diagnosis  difficult, 
particularly  so  in  cases  of  periosteal  abscess  in 
the  upper  maxilla  due  to  an  injury.  If  the 
maxillary  stricture  sets  in  immediately  after  the 
injury  lockjaw  is  contraindicated,  but  if  the 
stricture  persists  while  the  abscess  recedes  true 
trismus  is  affirmed.  In  some  rare  cases  of  acute 
rheumatism  of  the  temporalis  muscle  similar 
conditions  have  been  observed  (Oppoher). 

I  recall  two  interesting  cases  of  pseudotrismus 
in  two  soldiers.  One  was  that  of  a  military 
surgeon  who  attended  a  wounded  man  with 
tetanus  infection,  the  other  was  an  infantryman 
who  lay  in  the  bed  next  to  that  of  a  patient 
afflicted  with  trismus  and  subsequent  tetanus. 
Within  twenty-four  hours  both  men  were  at- 


MUSCLES  383 

tacked  by  trismus.  They  were  unable  to  open 
their  mouths,  the  private  soldier  even  showing 
signs  of  hysteria.  A  clear  proof  of  pseudo- 
trismus  caused  by  imitation  neurosis. 

In  hysteria  analogous  phenomena  have  been 
observed.  A  local  trauma,  e.g.,  a  gunshot 
wound  in  the  face  may  produce  an  hysterical 
maxillary  stricture  with  synchronous  analgesia 
of  the  face.  Under  suggestion  the  trouble  gen- 
erally disappears.  The  diagnosis  should  not  be 
difficult  if  we  pay  attention  to  the  other  typical 
signs  of  hysteria. 

Trismus  is  frequently  an  early  symptom  of 
tetanus.  Here,  too,  the  diagnosis  is  obvious  on 
the  strength  of  the  usual  tetanic  characteristics. 

Epidemic  and  tuberculous  meningitis  as  well 
as  epidemic  encephalitis  frequently  present  in 
their  incipient  stages  the  clinical  picture  of  tris- 
mus, and  in  many  cases  of  poisoning  lockjaw 
is  an  accompanying  manifestation.  If  a  patient 
shows  signs  of  trismus  coupled  with  intensive 
headache,  pressure  sensitiveness  in  the  head  or 
cerebral  vomiting  we  should  more  coftectly  diag- 
nose meningitis  as  the  originating  cause  and  not 
trismus  or  tetanus.  Lumbar  puncture  will  fur- 
nish additional  proof.  From  a  similar  stand- 
point we  can  also  explain  the  occurrence  of 
trismus  besides  other  cerebral  symptoms  in  per- 
nicious anemia  of  the  cerebral  type. 

In  other  acute  infections  initial  trismus  may 


384  GENERALIZED   PAIN 

be  the  effect  of  the  bacterial  poisons  on  the  brain, 
e.g.,  in  recurrent  fever,  in  which  disease  the  mus- 
cles at  times  are  so  stiffened  that  a  suspicion  of 
tetanus  is  pardonable.  Diphtheria,  erysipelas, 
influenza,  Weil's  disease  and  ton$illar  angina  are 
other  pertinent  instances.  In  typhoid  fever 
trismus  is  more  common  in  the  final  stages. 
When  it  occurs  in  any  of  these  infectious  dis- 
eases it  must  be  taken  as  a  definite  proof  of  very 
severe  bacterial  intoxication  and  of  great  signifi- 
cance for  the  prognosis,  more  so  even  than  clonic 
cramps  in  the  masseters  or  grating  of  the  teeth. 

But  it  is  not  only  general  toxic  conditions  but 
also  strongly  localized  diseases  of  the  brain  from 
which  trismus  may  result  that  lasts  for  weeks, 
months  and  even  years,  e.g.,  a  tumor  (tubercle) 
in  the  posterior  pons  or  a  softening  process  from 
sclerosis  or  a  syphilitic  endarteritis  of  the  basilary 
artery  caused  by  an  irritation  of  the  motoric 
trigeminus.  We  can  in  this  manner  explain  the 
occurrence  of  trismus  and  grating  of  the  teeth 
in  meningitis  and  in  pseudomeningitis  for  which 
a  basal  posferior  meningitis  is  responsible. 

In  some  cases  of  tetany  trismus  is  also  de- 
veloped. The  differentiation  between  tetany  and 
tetanus  is  discussed  elsewhere. 

If  trismus  occurs  in  trichinosis  it  is  of  peri- 
pheral and  not  central  origin  and  a  proof  of 
the  presence  of  trichina?  in  the  masseter  muscles. 

In  endogenous  poisoning  trismus  is  likewise  a 


MUSCLES  385 

possibility.  It  may  be  a  manifestation  in  part 
of  icterus,  of  cholemia  or  pellagra.  Perhaps 
more  frequently  and  mostly  coupled  with  other 
cerebral  symptoms  it  is  an  associate  of  certain 
acute  exogenous  intoxications,  chiefly  blood  poi- 
soning (hydrocyanic  acid,  aniline,  coal  gas,  coal 
dust,  hemlock,  helvella,  fly  agaric,  scorpion  poi- 
son). In  acute  atropin  poisoning  trismus  may 
occur  in  combination  with  loss  of  consciousness, 
Argyll-Robertson  sign,  absolute  dryness  of  the 
mucous  membrane  of  the  mouth,  erythema,  etc. 
Acute  nicotinism  belongs  here,  too.  Yet,  in  all 
these  conditions  trismus  does  not  occupy  a  very 
prominent  position,  if  we  except  acute  strych- 
nine, opium  and  morphine  poisoning,  especially 
in  children.  In  these  cases  trismus  may  be  an 
isolated  condition  or,  perhaps,  a  partial  manifes- 
tation of  generalized  tetanic  convulsions. 

True  infectious  tetanus  is  always  primarily 
suggested  when  the  patient  manifests  sudden 
attacks  of  painful  convulsions  in  the  masseter 
or  nuchal  muscles.  These  paroxysms  (local  or 
universal)  come  on  spontaneously  or  may  be 
reactions  of  external  causes,  and  are  felt  by  the 
patient  like  the  thrust  of  a  dagger  generally  in 
the  injured  part  of  the  body.  They  are,  so  to 
speak,  a  kind  of  tetanic  aura  preceding  the 
general  spastic  attack.  Nevertheless,  they  may 
just  as  well  constitute  the  solitary  symptom  of 
a  tetanus  infection  which  persists  as  "local  te- 


386  GENERALIZED   PAIN 

tanus"  without  development  of  a  generalized 
state  of  tetanus.  I  have  given  full  details  about 
this  subject  in  the  chapter  on  "Pains  in  the 
Extremities." 

If  the  bacteriological  examination  of  the 
wound  fails  to  show  the  presence  of  the  tetanus 
bacillus  we  must  look  for  other  morbid  processes 
which  are  known  to  produce  analogous  tetanic 
convulsions. 

Among  these  strychnine  poisoning  is  the  first 
to  be  considered.  Here  we  find  spasms  in  the 
extensor  muscles  of  a  tetanic  nature  with  risus 
sardonicus  and  yet  unclouded  mind,  reflectoric 
hyperexcitability  of  the  patient,  retention  of 
urine,  dysuria,  rising  temperature  and  profuse 
perspiration.  If  anamnetic  data  are  wanting, 
but  we  discover  a  wound  or  a  scar  on  the  body 
of  the  patient,  a  differential  diagnosis  between 
strychnine  poisoning  and  tetanus  will  be  impera- 
tive. We  can  arrive  at  a  proper  recognition  of 
tetanus  by  jts  gradual  development.  We  first 
witness  trismus,  then  opisthotonos  and  after  that 
generalized  extensor  convulsions.  In  acute 
strychnine  poisoning,  on  the  other  hand,  the 
universal  cramps  set  in  all  of  a  sudden,  some- 
times, it  is  true,  after  short  precursory  symptoms. 
It  stands  to  reason  that  in  most  instances  we 
are  not  able  to  observe  these  various  stages.  In 
fact,  it  is  most  difficult  to  ascertain  in  the  vast 
majority  of  cases  what  has  happened  previous 


MUSCLES  387 

to  the  real  attack.  Then  we  must  lean  on  the 
fact  that  in  strychnine  poisoning  the  muscles 
relax  during  the  intervals  between  the  spastic 
attacks.  The  patient  is  able  to  move  freely,  can 
even  stand  on  his  feet  without  assistance;  whilst 
in  tetanus  the  muscles  remain  rigid  until  recov- 
ery ensues.  And,  again,  tetanus  is  a  long  con- 
tinued disease,  while  in  strychnine  poisoning  the 
cramps  (chiefly)  in  the  extremities — especially 
in  the  hands — soon  pass  away.  I  do  not  know 
whether  in  strychnine  poisoning  leucocytosis  and 
eosinophilia,  so  common  in  tetanus,  are  also 
found. 

Tonic,  tetaniform  convulsions,  opisthotonos, 
increased  reflex  action  and  also,  it  is  claimed, 
leucocytosis  are  also  observed  in  hydrophrobia. 
It  is  distinguished  from  tetanus  and  strychnine 
poisoning  by  absence  of  trismus,  by  the  fear  of, 
or  inability  to  swallow  water,  fear  of  water, 
psychic  agitation  and  a  feeling  of  anguish.  Fur- 
thermore, the  anamnesis  and  the  fact  that  in 
rabies  the  muscles  in  general,  but  especially  those 
in  the  nape  of  the  neck  and  of  the  masticatory 
apparatus,  relax  in  between  the  spasms,  are  an 
additional  help.  Under  the  heading  of  dys- 
phagia  I  speak  of  the  differential  diagnosis 
between  hydrophobic  tetanus  and  hydrophobia. 
I  will,  however,  mention  that  in  the  former  the 
muscles  of  deglutition  and  those  of  the  dia- 
phragm are  deeply  involved. 


388  GENERALIZED   PAIN 

Hysteria  also  breeds  sometimes  painful,  te- 
taniform  extensor  cramps.  I  have,  indeed,  seen 
myself  a  case  of  acute  strychnine  poisoning 
which  was  erroneously  labeled  "hysteria."  The 
differential  diagnosis  must  be  built  upon  the 
anamnesis,  the  presence  of  other  symptoms  char- 
acteristic of  hysteria  and  the  course  run  by  the 
disease.  Of  course,  it  is  always  possible  that 
an  individual  with  an  hysterical  taint  and  afflicted 
with  exaggeration  mania  may  at  any  time  ac- 
quire a  genuine  attack  of  tetanus. 

Similar  spastic  conditions  especially  in  the 
muscles  of  the  nape  of  the  neck,  the  back  and 
extremities^  follow  sometimes  in  the  wake  of  cere- 
bral affections,  but  they  are  free  from  pain  and 
do  not  affect  consciousness.  Here  we  find  mani- 
festations of  paresis  or  paralysis  of  the  cerebral 
nerves  which  might  suggest  tetanus  of  the  hand, 
unless  traces  of  a  local  wound  are  wanting.  We 
also  meet  with  bilateral  BabinsM's  toe  phenome- 
non and  unilateral  absence  of  abdominal  wall 
and  cremaster  reflexes.  Moreover,  lumbar  punc- 
ture yields  a  bloody-red  or  sanguinolent  cere- 
brospinal  fluid  containing  diluted  red  blood 
corpuscles  without  sendimentation — a  sure  proof 
of  cerebral  genesis.  But  I  emphasize  the  fact 
that  an  anemic  condition  of  the  blood  is  also 
found  when  the  puncture  is  made  only  sometime 
after  the  cerebral  hemorrhage  has  taken  place. 
If  we  are  enabled  to  make  the  puncture  soon — 


MUSCLES  389 

even  within  an  hour — after  the  injury,  we  are 
likely  to  find  perfect  red  corpuscles.  After  sedi- 
mentation the  cerebrospinal  fluid  may  appear 
tinged  with  blood  should  the  needle  have  passed 
through  a  meningeal  vein.  It  is  wise  to  watch 
the  fluid  whilst  it  is  being  drawn  and  see  if  it 
is  evenly  tinged  with  blood  all  throughout  the 
act  of  puncturing.  As  a  rule  the  first  portions 
alone  are  tinged  with  blood  or  at  any  rate  more 
so  than  those  that  follow.  If  the  patient  has 
been  lying  motionless  for  hours  when  we  arrive, 
we  may  well  exclude  tetanus  and  acute  strych- 
nine poisoning. 

When  extensor  convulsions  in  the  dorsal  mus- 
cles or  in  those  of  the  extremities  are  found  in 
a  patient  who  is  not  in  a  comatose  state  the 
foregoing  is  of  particular  moment  especially 
when  other  positive  or  negative  symptoms  affect- 
ing the  central  nervous  system  are  present. 

The  differential  diagnosis  must  be  made  from 
the  same  angle  in  those  rare  cases  of  cerebro- 
spinal meningitis  (purulent  epidemic  or  non- 
epidemic,  or  tuberculous)  which  give  rise  to 
tetanic  extensor  convulsions.  The  same  applies 
also  to  those  rare  cases  of  acute  encephalitis 
which  may  be  observed  after  acute  influenza  and 
likewise  of  saturnine  encephalopathia  which  is 
fully  dealt  with  in  the  volume  on  "Abdominal 
Pain"  under  the  title  of  "chronic  lead  poisoning." 

The  severe  form  of  arteriosclerosis  of  the  cere- 


390  GENERALIZED   PAIN 

bred  arteries  is  another  harbinger  of  painful  tonic 
muscle  clonus  in  the  trunk  and  in  the  extremities 
associated  with  mono-  and  hemiplegia,  disturb- 
ances of  speech  and  slight  apraxia. 

Fatty  embolism  of  the  brain  belongs  to  this 
section  also.  It  may  happen  in  babies  before 
the  foramen  ovale  has  closed  up  or  in  persons  of 
old  age  and  in  heavy  drinkers.  Although  this 
disease  is  of  minor  interest  to  the  internist  I 
deem  it  advisable  to  mention  that  we  find  here 
cerebral  irritations  in  the  sense  of  trismus,  opis- 
thotonos  and  spastic  attacks  chiefly  of  an  epilep- 
tiform  character,  followed  a  few  hours  later  by 
dullness  in  the  sensorium  and  a  small,  irregular 
pulse.  But  the  involvement  of  consciousness  is 
the  master  key  to  the  diagnosis  which  might  be 
led  into  an  error  by  the  fact  that  in  tetanus  also 
there  is  serious  destruction  in  the  tissues  and 
vessels. 

Similar  tonic  spasms  are  often  observed  in 
cerebellar  tumors  in  which  opisthotonos  is  not  an 
infrequent  accompanying  symptom.  It  would 
be  superfluous  to  discuss  here  the  other  typical 
signs  of  these  tumors.  This  refers  with  equal 
force  to  tumors  of  the  pons  and  of  the  medulla 
oblongata  in  which  every  form  of  tonic  spasms, 
light  convulsive  tremor  and  slightly  clouded 
consciousness  is  of  diagnostic  import. 

ftleningeal  hemorrhages  give  rise  to  muscular 
contractions  which  strongly  resemble  convulsions 


MUSCLES  391 

so  typical  of  strychnine  poisoning.  The  behavior 
of  the  sensorium  and  of  the  cerebral  nerves  and 
lumbar  puncture  are  generally  sufficient  to  throw 
the  proper  light  on  the  situation. 

Spasms  of  this  tetanic  character  are,  however, 
quite  common  in  a  number  of  exogenous  poison- 
ings such  as  carbon  dioxid,  sewer  gas,  arsenic, 
mercury,  alcohol,  dicyanogen,  nitrobenzol  iodo- 
form.  The  coincidence  of  the  cerebral  manifesta- 
tions, i.e.,  loss  of  consciousness  and  simultaneous 
spasms,  are  the  strongest  differential-diagnostic 
points  in  these  cases. 

Acute  cases  of  opium  or  morphine  intoxication 
are  to  be  included  here,  especially  in  children. 
Trismus,  opisthotonos  and  tonic  spasms  are  al- 
ways present.  The  diagnosis  results  from  the 
observation  of  the  comatose  state,  the  want  of 
reaction  to  light  in  the  closed  pupils,  of  brady- 
cardia,  bradypnea,  fall  of  body  temperature  and 
the  presence  of  the  drug  in  the  saliva,  the  urine 
and  the  gastric  contents. 

In  ergot  poisoning  the  tonic  spasms  do  not 
only  affect  the  extremities  but  also  the  muscles 
in  the  back,  in  the  throat  and  in  the  diaphragm, 
lasting  continuously  sometimes  for  days.  The 
diagnosis  is  materially  assisted  when  gangrenous 
spots  in  the  skin  are  observed  and  when  a  pain- 
ful creeping  sensation  has  made  itself  felt  all 
over  the  body  for  some  time  previous  to  the 
spastic  onset. 


392  GENERALIZED   PAIN 

There  are  some  cases  of  diphtherin  poisoning 
on  record  which  are  called  "spasmogenous  diph- 
theria" in  which  tonic  spasms  are  observed,  but 
I  cannot  speak  from  personal  experience  on  this 
matter.  The  symptoms  are  described  as  follows: 
presence  of  bacillus  diphtherias  in  nose  and 
throat,  diphtheritic  membranes,  inefficiency  of 
antitetanus  serum,  reaction  to  diphtheritic  anti- 
toxin. 

Escherich  and  v.  Jacksch  speak  of  pseudo- 
tetanus,  a  condition  of  generalized  tonic  cramps 
in  the  articular  muscles  of  the  jaws,  the  nape 
of  the  neck  and  the  back  which  continue  for 
months  at  a  time  and  are  caused  by  some  infec- 
tious disease.  When  it  exists  as  an  independent 
disease  the  tonic  spasms  affect  principally  the 
lower  extremities;  trismus  sets  in  later  on.  It 
yields  to  treatment. 

Kollert  describes  tetanus-like  conditions  in 
some  severe  cases  of  spotted  typhus.  In  tropical 
malaria  cerebral  symptoms  such  as  delirium, 
eclampsia  and  coma  are  not  uncommon  mani- 
festations. 

In  uremia  tonic  as  well  as  clonic  spasms  are 
observed.  The  diagnosis  can  be  made  without 
difficulty. 

Painful  muscular  cramps  in  eclampsia  and 
epilepsy  are  sometimes  erroneously  taken  for  a 
symptom  of  acute  strychnine  poisoning.  But 
the  mistake  can  be  easily  prevented  if  proper 


MUSCLES  393 

attention  is  given  to  the  presence  of  edematous 
conditions  in  the  skin  and  of  albuminuria  so 
typical  of  the  former  diseases,  and  the  solitary 
attack  of  convulsions  and  their  clonic  character, 
the  total  loss  of  consciousness  during  the  attack, 
the  involuntary  discharge  of  urine  and  feces, 
bites  in  the  tongue,  the  want  of  pupillary  re- 
action and  the  anamensis  in  the  case  of  strych- 
nine poisoning. 

There  are  likewise  cases  of  tetany  in  which 
the  spasms  involve  the  whole  body  with  the  pres- 
ence of  opisthotonos  and  trismus  which  may  put 
a  mistaken  diagnosis  of  tetanus  within  the  range 
of  possibilities.  But  the  want  of  reflex  action 
characteristic  of  tetanus,  the  presence  of  the 
cardinal  symptoms  of  tetany,  the  mechanical 
overexcitation  of  the  motoric  nerves  (the  facial 
phenomenon),  the  hyper-reaction  of  the  motoric 
nerves  to  the  electric  current  (Erb's  phenome- 
non) and  Trousseau's  sign  (the  arrest  of  the 
typical  spastic  attack  by  compression  of  the  sul- 
cus  bicipitalis  internus)  should  clearly  establish 
the  differentiation. 

A  long  continued  exposure  to  heat,  e.g.,  work- 
ing in  an  overheated  boiler  room,  i.e.,  collapse 
from  heat,  provokes  tetanic  muscular  spasms 
with  trismus,  no  doubt  due  to  the  enormous  loss 
of  water  in  sweating.  The  same  may  be  said  of 
sunstroke  or  heatstroke  which,  clinically  speak- 
ing, strongly  resemble  uremia:  total  loss  of  con- 


394  GENERALIZED   PAIN 

sciousness,  pulse  hardly  perceptible,  respiration 
suspended,  pale,  cyanotic  appearance  of  the 
face,  very  high  body  temperature,  tetanic  mus- 
cular contractions  and  trismus  are  the  outstand- 
ing features  of  this  condition  which  is  due  to 
abnormal  over-exertion  of  the  cardiac  organs  and 
excessive  action  of  the  respiratory  muscles. 


Pain  in  the  Bones 

When  a  patient  complains  of  pain  in  a  bone 
and  we  find  local  changes  and  tenderness,  the 
diagnosis  is  simple  enough.  However,  when  the 
complaint  is  of  a  rather  vague  nature,  for  in- 
stance, of  rheumatic,  steady  or  variable  or 
intermittent  pain  now  in  the  arm,  then  in  the 
leg,  but  with  varying  intensity,  the  thought  of 
a  muscular  affection  will  be  uppermost  in  our 
mind,  and  yet  the  originating  cause  may  lie  in 
a  morbid  condition  of  the  bones.  A  careful 
search  for  local  tenderness  or  swelling  in  the 
osseal  parts  will  soon  correct  our  first  impres- 
sion. Many  diseases  of  the  bones  can  be  readily 
diagnosed  in  this  manner. 

I.  Unilocular  Pain  in  the  Bones 

If  we  find  local  sensitiveness  on  pressure  or 
percussion  with  or  without  anomalous  configura- 
tions we  are  confronted  either  by  a  purely 
regional,  local  disease  or  with  the  manifestation 
of  a  multilocular  affection  which  is  as  yet,  or 
may  be  permanently  localized  in  that  spot. 

In  the  first  case  we  are  dealing  with  the  vari- 
ous forms  of  osteoperiostitis  as  well  as  with  the 
local  primary  and  metastatic  neoplasms  of  the 


396  GENERALIZED   PAIN 

bones.  These  belong,  in  part  at  least,  in  the  field 
of  internal  medicine,  but  chiefly  affect  the  sur- 
geon. Those  of  interest  to  the  internist  will 
engage  our  attention  in  the  succeeding  pages. 

The  first  to  speak  of  is  syphilitic  osteoperi- 
ostitis together  with  that  of  tuberculous,  actino- 
mycotic  and  malleose  genesis,  and  also  acute  as 
well  as  chronic  osteomyelitis.  They  will  all  be 
discussed  in  separate  paragraphs.  But  I  must 
add  here  various  other  divisions  of  secondary, 
infectious  osteoperiostitis  which  follow  in  the 
wake  of  divers  infectious  diseases.  Among 
these  I  mention  acute  articular  rheumatism  (os- 
teoperiostitis rheumatica  and  postrheumatica) 
with  demonstrable  swellings  sometimes  of  the 
character  of  albuminous  osteoperiostitis  or  with 
limited  sensitiveness  in  the  bones,  for  instance 
in  the  calcaneum;  likewise  purulent  infections 
and  infections  from  the  paratyphoid  bacillus, 
bacterium  coli  or  dipplococcus  (pyemia) ;  fur- 
ther, typhoid  fever,  smallpox,  measles,  scarlet 
fever,  influenza,  bacilary  dysentery  and  gonor- 
rhea. 

In  many  of  the  aforementioned  infections 
the  morbid  affection  of  the  bones  and  the  accom- 
panying pains  are  merely  a  distinct  expression 
of  the  gradual  development  of  the  disease  itself; 
even  though  superficial  reddening  of  the  skin, 
and  swelling  or  enlargement  of  the  bones  are 
not  yet  in  evidence.  Of  course,  we  must  not 


BONES  397 

forget  that,  when  the  generalized  infection  has 
been  fully  developed,  the  accompanying  pain  in 
the  bones  may  just  as  well  be  the  expression  of 
the  generalized  infection  itself  although  inflam- 
matory neurotic  changes  in  the  bones  are  not 
present  at  all.  In  that  case  we  are  not  dealing 
with  one  solitary  local  focus  but  with  multiple 
foci  for  the  pain,  especially  so  when  these  pains 
are  not  spontaneous  but  only  ensue  from  provo- 
cation. 

This  painful  focus  in  the  bone,  on  the  other 
hand,  may  just  as  well  be  the  first  and  only 
spot  where  the  disease  is  localized.  This  is  the 
case,  e.g.,  in  acute  osteomyelitis,  although  this 
disease  is  often  enough  localized  in  several  places 
either  at  the  same  time  or  in  successive  periods. 
It  happens  also  in  actinomycotic,  tuberculous  or 
syphilitic  osteoperiostitis.  In  this  the  primary 
port  of  entry  of  the  infection  is  not  always 
apparent,  a  careful  search  may  reveal  it,  but 
often  enough  it  remains  an  unsolved  problem. 
A  similar  dilemma  faces  us  sometimes  in  other 
forms  of  post-infectious  osteoperiostitis  in  which 
the  generalized  infection  and  the  manifestation 
of  the  local  focus  of  the  pains  are  often  years 
apart,  for  instance  typhoid  periostitis  which  may 
set  in  on  the  orbital  margin  or  on  the  skull  even 
during  the  first  week  of  the  disease. 

These  cases  are  very  difficult  to  diagnose. 
Only  the  widest  search  for  every  detail  that 


398  GENERALIZED   PAIN 

might  possibly  be  of  use  can  clear  the  situation. 
We  may  find,  for  instance,  a  sign  of  ostitis 
(acute,  chronic,  purulent  or  plastic)  on  a  rib, 
on  the  sternum,  on  the  tibia  or  on  a  vertebra 
or  even  on  the  skull.  There  we  have  a  sugges- 
tion of  lues  or  tuberculosis.  We  may  hear  of 
an  attack  of  typhoid  fever,  ten,  fifteen  or  even 
twenty  years  ago,  when  typhoid  periostitis  would 
not  be  an  improper  guess,  or  we  may  be  dealing 
with  a  case  of  autointoxication  of  a  chronic 
typhoid  bacillus  carrier,  due  to  some  trouble  of 
the  gallbladder.  A  bacteriological  examination 
of  the  contents  of  the  lesion  is  very  seldom  at- 
tainable, but  the  Gruber-Widal  reaction,  repeat- 
edly made  during  the  course  of  the  disease,  will 
very  likely  give  us  the  right  clue,  especially 
when  antisyphilitic  treatment  has  proved  ineffec- 
tive. But  even  so,  a  positive  Gruber-Widal 
reaction  or  the  anamnesis  are  not  always  abso- 
lutely reliable  indications. 

I  may  mention  also  that  the  nocturnal  habit 
of  the  pains  is  not  always  a  definite  proof  of 
their  syphilitic  genesis.  We  find  it  also  in  ty- 
phoid and  posttyphoid  osteoperiostitis,  not  to 
speak  of  carcinomatous  metastasis  of  the  bones 
and  above  all  gouty  pains  in  the  bones.  The 
latter  would,  however,  rather  represent  articular 
pains  owing  to  the  presence  of  uric  acid  in  the 
articular  ends  of  the  bones. 

At  any  rate  in  these  complicated  cases   we 


BONES  399 

shall  derive  much  help  from  the  local  condition, 
the  X-ray,  the  serological  examination  and  ten- 
tative antisyphilitic  treatment. 

But  there  are  very  stubborn  cases  of  syphilitic 
ostitis  which  resist  every  form  of  specific  thera- 
peutic measure  or  at  the  utmost  give  only  a 
fleeting  reaction. 

The  diagnosis  of  the  other  forms  of  osteoperi- 
ostitis  generally  results  from  the  anamnesis  of 
the  causating  acute  infection.  With  regard  to 
gonorrhea  I  must  add  that  this  disease  may,  in 
rare  cases,  give  rise  to  an  attack  of  osteoperi- 
ostitis  (e.g.,  in  the  clavicle  or  femur)  of  such 
magnitude  that  an  erroneous  diagnosis  of  a  sar- 
coma may  easily  creep  in. 

There  is  a  special  lower  form  of  periostitis 
which  is  mostly  of  a  localized,  although  at  times 
also  of  a  multiple  character,  which  deserves 
special  mention  here,  viz.,  angio-neurotic  pseudo- 
periostitis.  Angio-neurotic  processes  provoke 
very  transient  but  ever  recurring  exudates  in  the 
skin  and  mucous  membranes  and  also  in  the 
joints.  We  call  them  hydrops  hypostrophos.  But 
similar  conditions  may  also  be  observed  on  the 
peristeum.  We  find  swellings  in  certain  parts 
of  the  bones  which  come  on  suddenly,  are  of  a 
doughy  consistence,  spontaneously  painful  and 
very  sensitive.  They  generally  localize  in  one 
of  the  ribs  or  in  the  sternum.  In  the  fleeting 
character  of  these  swellings,  in  their  variability 


400  GENERALIZED   PAIN 

of  localization,  in  the  similarity  of  the  symptoms 
to  those  of  hydrops  hypostrophos  we  find  the 
key  to  the  proper  recognition  of  this  disease. 
Among  the  concomitant  symptoms  we  count, 
asthmatic  attacks,  mucous  colitis,  vasomotoric 
rhinitis,  urticaria  and  vasomotoric  disorders  of 
the  skin.  All  these  manifestations  are  comprised 
in  the  term  "exudative  diathesis"  recently  intro- 
duced in  medical  literature. 

In  Sudek's  atrophy  of  the  bones  active  as  well 
as  passive  movements  provoke  serious  pains  in 
the  bones  and  are  an  important  symptom  of  this 
affection.  As  it  is  a  surgical  disease  I  cannot 
claim  personal  knowledge  of  it,  but  the  symp- 
toms are  described  as  follows.  It  sets  in  after 
inflammatory  processes  in  the  cellular  tissue 
which  are  of  simple,  tuberculous,  probably  also 
syphilitic  and  gonorrhoic  origin,  specifically  also 
after  injuries  to  the  bones.  The  distinguishing 
symptoms  are:  a  characteristically  hard,  doughy 
edema  of  the  subcutaneous  cellular  tissue,  coupled 
with  malnutrition  of  the  softer  tissues,  a  shiny, 
bluish-red  skin,  copious  sweating  and  a  feeling 
of  cold  in  the  morbid  section.  The  X-ray  is 
an  important  factor  in  the  diagnosis. 

In  local  processes  caused  by  neoplasms  the 
diagnosis  will  not  be  difficult,  if  we  find  demon- 
strable changes,  such  as  thickening  or  enlarge- 
ment of  the  bones,  especially  if  the  parchment 
crackling  sound  is  present.  The  X-ray  should 


BONES  401 

prove  of  great  assistance,  but  in  cases  in  which 
it  cannot  be  employed,  mistakes  are  not  always 
avoidable.  A  sarcoma  may  be  taken  for  osteo- 
periostitis  resp.  osteomyelitis,  for  frequently  the 
fact  is  overlooked  that  in  sarcoma  also  the  skin 
over  the  swelling  feels  hot  and  is  very  sensitive. 
Let  us  remember  that  in  primary  neoplasms  the 
skin  is  distinctly  interwoven  with  enlarged  blood 
vessels. 

Metastatic  neoplasms  require  the  attention  of 
the  internist  as  well  as  that  of  the  surgeon,  for 
in  many  cases  abnormal  conditions,  or  even  sensi- 
tiveness in  the  bones  cannot  be  detected.  This 
makes  it  very  difficult  to  form  an  opinion 
whether  the  painful  sensation  arises  from  an 
affected  bone  or  is  due  to  some  other  cause.  The 
situation  is  improved  if  we  can  find  the  evidence 
of  a  previous  primary  neoplasm,  no  matter  how 
large  or  little,  for  that  might  put  us  on  the  right 
track  in  our  search  for  the  genesis  of  the  pain. 
We  might  be  told,  for  instance,  that  five  or  ten 
years  ago  a  primary  neoplasm  was  removed  from 
the  mamma.  It  is  exactly  this  kind  of  case  in 
which  late  metastases  of  the  bones  develop. 
Another  point  worth  mentioning  is  that  primary 
neoplasms  generally  are  formed  in  just  such 
places  where  metastases  of  the  bones  prefer  to 
develop.  I  mean  the  mamma,  the  thyreoid  gland, 
the  prostate,  the  adrenals  (hypernephroma),  the 
ovaries,  the  male  genitals  (testicles),  bronchi, 


402  GENERALIZED   PAIN 

stomach  and  sigmoid.  Sometimes  these  primary 
tumors  escape  our  clinical  observations  because 
they  are  so  small  and  hardly  palpable,  when  the 
metastatic  conditions  in  the  bone  marrow  are 
already  provoking  most  painful  sensations.  This 
is  particularly  the  case  in  malignant  primary 
new  growths  of  the  thyreoid  and  prostate.  The 
spinal  localization  of  the  pains  in  any  of  these 
parts  is  always  a  suspicious  signal.  When  the 
pains  are  localized  near  the  head  of  the  upper 
arm  or  of  the  thigh,  or  in  the  pelvic  region  or 
in  the  zone  of  a  vertebra  belonging  to  the  lower 
costal  or  to  the  lumbar  spinal  column,  or  in  one 
of  the  ribs  or  in  the  sternum,  especially  when 
these  thoracic  pains  are  provoked  by  motation 
or  impair — completely  arrest — the  motor ic  ac- 
tion of  the  gait,  and  we  cannot,  on  the  other 
hand,  discover  a  demonstrable  cause  for  these 
manifestations,  then  we  have  sufficient  ground 
for  suspecting  the  development  of  a  metastatic 
carcinoma  of  the  bones. 

Similar  metastafic  conditions  are  found  in 
simple,  but  not  malignant  colloid  struma.  They 
are  generally  combined  with  other  metastases  in 
the  skin,  mucous  membranes,  etc. 

Pains  localized  in  one  bone  only  may  be  the 
reflex  action  of  a  morbid  process  which  is  in  the 
initial  or  rudimentary  stage  of  development  in 
other  sections  of  the  skeletal  frame.  I  refei 
particularly  to  Paget's  ostitis  deformans  which 


BONES  403 

may  exist  in  only  one  leg  for  a  number  of  years. 
The  diagnosis  should  offer  no  difficulty,  espe- 
cially when  the  characteristic  thickening,  soften- 
ing and  curvature  of  the  tibia  is  in  evidence. 
The  more  so,  when  the  patient  is  beyond  the 
forties  and  the  pains  are  rather  severe,  neuralgi- 
form  and  constant.  Besides,  the  Roentgen-ray 
should  support  the  diagnosis.  Syphilis,  of  course, 
is  the  only  other  alternative,  but  the  Wassermann 
reaction  and  specific  treatment  are  in  this  case 
the  distinguishing  features,  unless  both  diseases 
co-exist. 

When  the  cranial  bones  are  the  home  of  the 
pains  we  are  very  likely  confronted  by  diffuse 
or  tumorous  hyperostosis.  I  shall  speak  of  the 
differential  diagnosis  later  on.  I  will  mention, 
however,  that,  when  the  jaw  bones  are  affected 
we  must  differentiate  between  maxillary  hyper- 
ostosis  and  syphilis  as  well  as  neoplasms  of  the 
bones,  chiefly  sarcoma. 

Fibrous  ostitis  is  in  most  cases  a  generalized 
disease  of  the  bones,  but  in  the  circumscribed 
form  it  prefers  the  long  bones  for  the  place  of 
attack.  Spontaneous  fractures  are  frequently  a 
telling  factor.  The  X-ray  reveals  their  nature 
(cyst  formations). 

There  is  a  localized  form  of  rachitis  tarda  of 
which  I  shall  speak  later  on.  I  will  only  men- 
tion here  so  far  as  the  diagnosis  is  concerned, 
that  the  Roentgen-ray  is  the  most  reliable  item. 


404  GENERALIZED   PAIN 

We  should  look  for  localized  changes  in  the 
bones  of  the  leg  and  the  spinal  column  (genu 
valgum,  pes  valgus,  kyphosis  and  scoliosis  of 
the  spinal  column,  coxa  vara  in  the  adolescent). 
Other  symptoms  are  paleness  of  the  face,  ab- 
normal fatigue  and  arrest  of  physical  growth. 

Other  unilocular  affections  of  the  bones  such 
as  syphilitic,  actinomycotic  or  tuberculous  ostitis, 
and  scleroma,  will  be  discussed  when  we  come 
to  the  multilocular  conditions. 

Greater  difficulties  surround  the  diagnosis 
when  the  pains  are  localized  not  only  in  one 
place,  but  are  spread  over  various  portions  of 
the  body.  The  patient  locates  them  deep  down 
in  the  bones,  or  he  may  only  complain  of  "rheu- 
matic" sensations.  We  should  resort  to  the 
usual  pressure  and  percussion  methods.  If  we 
find  local  sensitiveness  we  have  several  problems 
to  solve.  The  alternatives  are:  acromegaly  with 
pains  of  minor  importance;  multiple  osteomye- 
litis ;  various  forms  of  multilocular  ostitis  ( syphi- 
lis and  tuberculosis) ;  osteomalacia ;  osteoporosis; 
rachitis  tarda ;  metastatic  and  primary  neoplasms ; 
Paget's  ostitis;  diffuse  hyperostosis. 

It  may  help  the  student  of  this  book  very 
much  if  he  ever  keeps  in  mind  that  he  is  dealing 
with  a  disease  of  the  bones  when  the  patient 
complains  of  periodic,  or  constant  pains,  now  of 
a  decidedly  boring,  tearing  or  shooting  character, 
or  of  a  vague,  indefinite,  rheumatic  nature. 


BONES  405 

First  in  line  is  acromegdLy.  The  differential 
diagnosis  will  be  found  at  the  end  of  this  chapter, 
and  its  initial  symptoms  have  already  been  dis- 
cussed in  the  chapter  on  "Pain  in  the  Extremi- 
ties." The  diagnosis  is  not  hard  to  make  when 
the  disease  is  fully  developed.  The  outstanding 
signs  are:  the  progressive  enlargement  of  the 
skull,  the  nose,  the  lower  jaw,  the  lips  and  the 
tongue,  the  hands  and  feet  and  of  the  overlying 
parts.  We  also  find  marked  spacing  between 
the  teeth,  sexual  impotence,  atrophy  of  the 
genitals.  Further,  the  enlargement  of  the  hypo- 
physis causes  local  symptoms  such  as,  exoph- 
thalmos,  paralysis  of  the  optic  muscles,  visual 
impairment,  bitemporal  more  frequently  than 
homonymous,  morbid  changes  in  the  optic  nerve 
(reactions  of  the  pupils,  atrophy),  cerebral  pres- 
sure symptoms  (headache,  dizziness,  weak  mem- 
ory, apathy) ,  sleeplessness,  moodiness,  depression, 
enlargement  of  the  larynx,  abnormally  deep, 
raucous  voice,  rigidity  of  the  chest,  kyphosis  and 
cuplike  dullness  over  the  upper  sternum.  The 
X-ray  will  reveal  the  conditions  in  the  sella 
turcica  (abnormal  dimension  in  the  sagittal  di- 
rection) .  Diffuse  hyperostosis  and  Paget's  osti- 
tis  are  closest  in  resemblance. 

The  differential  diagnosis  of  osteomalacia  will 
be  more  fully  discussed  at  the  end  of  this  chap- 
ter. The  pregnancy  (puerperal)  form  is  easy 
to  diagnose.  When  a  pregnant  or  parturient 


406  GENEBALIZED   PAIN 

patient  complains  of  rheumatic  pains  be  on  the 
watch  for  a  case  of  osteomalacia. 

The  characteristic  symptoms  are:  the  pains 
are  localized  in  the  pelvic  region  near  the  last 
vertebra  and  gradually  extend  into  the  trunk 
and  thighs,  rarely  into  other  extremities,  scarcely 
ever  in  the  head,  later  on  they  increase  in  violence 
during  the  menstrual  flow  and  in  subsequent 
pregnancies;  wattling  gait,  clumsy  movement  of 
the  body,  spasms  of  the  adductors,  increased 
patellar  reflexes,  tenderness  in  the  bones,  espe- 
cially the  ribs,  abnormal  flexibility  of  the  bones 
(feathering  pelvis,  feathering  ribs,  etc.),  unusual 
softness  and  deformities  (osteomalacia  pelvis, 
kyphosis),  indentation,  especially  of  the  lumbar 
vertebras  and  subsequent  shrinkage  of  stature, 
the  dimensions  of  the  body  are  out  of  propor- 
tion to  the  length  of  the  legs,  the  costal  arches 
almost  touch  the  upper  pelvis,  causing  a  deep 
furrow  in  the  waist  line,  lateral  bending  of  the 
ribs,  arching  of  the  sternum  (chicken  breast)  or 
depression  of  it,  later  on  bow-leggedness,  in- 
fractions or  fractures  on  impacts  ever  so  light, 
slightly  brisk  muscular  action  and  surprising 
fluctuations  in  the  intensity  of  the  morbid  symp- 
toms. 

Tardive  or  senile  osteomalacia  occurs  also  in 
men.  It  differs  from  the  former  in  many  ways, 
viz.,  it  chiefly  begins  in  the  bones  of  the  trunk. 
There  are  pains  in  the  ribs  and  pains  and 


BONES  407 

formities  in  the  vertebrae  (arcuary  kyphosis), 
depression  of  the  chest,  sensitiveness  of  the  spinal 
column  on  pressure,  a  strong  compression  of 
the  thorax  is  painful,  girdle  sense,  pains  and 
changes  in  the  legs  and  thighs,  the  long  bones 
are  flexible  but  do  not  break  easily,  muscular 
contractions  especially  of  the  adductors,  knees 
and  thighs  are  closely  pressed  together  when 
standing  or  walking  (in  decubitus  contracture 
of  the  adductors  is  not  demonstrable)  and  shrink- 
age of  the  body.  Excruciating  pains  accom- 
pany this  tormenting  disease  through  many 
weary  years. 

Hunger-osteopathy  presents  pretty  well  the 
same  picture. 

Senile  osteomcdacia  is  easily  mistaken  for 
osteoporosis. 

In  the  latter  the  bones  are  very  brittle  and  do 
not  bend.  Spontaneous  fractures  of  the  femur, 
the  ribs,  clavicles,  sternum  and  spinal  column 
without  conspicuous  accompanying  symptoms 
are  frequently  found  in  Roentgengraphs.  More- 
over, osteoporosis  as  a  rule  involves  the  entire 
skeletal  system  including  the  skull  and  maxillse, 
but  shrinkage  of  the  body,  waiste-furrow  and 
wattling  gait  are  not  found. 

The  differentiation,  however,  of  senile  osteo- 
malacia  from  multiple  tumors  of  the  bones  is 
much  more  difficult.  Here  we  have  a  true  pic- 
ture of  "carcinomosteomalacia." 


408  GENERALIZED   PAIN 

In  juvenile  patients  the  question  lies  between 
osteomalacia  and  rickets,  if  a  differentiation  be- 
tween the  two  diseases  is  at  all  possible  because 
the  pains  in  both  diseases  are  almost  identical. 

Tardive  rachitis  runs  its  course  from  the 
eighth  year  after  birth  till  the  time  of  puberty. 
The  pains  are  chiefly  in  the  back  and  the  legs 
and  there  are  rosary-like  tuberosities  on  the 
antero-external  ridges  of  the  bones  and  on  the 
epiphyses,  and  we  observe  scoliosis  and  genua 
valga  and  vara  very  much  the  same  as  in  osteo- 
malacia. Differential  points  may  be  found  in 
several  respects  such  as  the  juvenile  age  of  the 
patient,  likelihood  of  infractions,  absence  of 
shortening  in  the  spinal  column  and  in  the  thorax, 
want  of  pressure  sensitiveness  in  the  chest  and 
pelvis  excepting  the  extremities,  pelvis  normal 
(not  beaked,  rostrated),  involvement  of  the  teeth, 
retarded  growth.  The  remaining  requisites  for 
a  positive  diagnosis  are  the  Roentgen  ray  and 
urine  and  blood  tests. 

Pains  in  the  bones,  physical  shrinkage  and 
spinal  curvature  have  in  recent  years  also  been 
observed  in  osteoporosis  attended  with  chronic 
bilious  fistulce. 

The  differential  diagnosis  between  senile  and 
carcinomatous  osteomalacia,  or  more  correctly 
speaking  multiple  metastases  of  the  bones,  can 
only  be  in  doubt  when  there  is  no  evidence  of 
an  existing  primary  neoplasm.  In  that  case 


BONES  409 

pains,  especially  in  the  thoracic  bones  excerbated 
by  motation,  are  common  factors.  This  refers 
also  to  conditions  which  prevail  in  cases  of  osteo- 
plastic  neoplasms  ( osteoplastic  new  growths  are 
recognized  by  the  increase  of  body  weight  despite 
progressive  cachexia).  We  find  brittleness  of 
the  bones,  deformities  in  the  trunk  due  to  colum- 
nar kyphosis  and  also  in  the  sternum,  the  ribs 
and  thighs,  kyphosis  in  the  lumbar  portions, 
changes  in  the  formation  of  the  pelvis  and  of 
the  proximal  parts  of  the  femur  and  shrinkage 
of  the  body  the  same  as  in  osteomalacia,  infrac- 
tions and  fractures,  remissions  and  intermissions 
and  a  long  protracted  illness.  But  if  we  can  feel 
a  protuberance  even  in  one  part  of  the  bone  only 
and  not  of  the  nature  of  a  callus — the  crista  ilei, 
the  ribs  and  the  skull  (hypernephroma  and  car- 
cinoma) are  favorite  spots — the  diagnosis  points 
to  an  existing  tumor.  When  this  sign  is  want- 
ing, the  Roentgen-ray  and  blood  tests  will  prob- 
ably furnish  the  required  proofs. 

In  osteomalacia  the  blood  test  as  a  rule  shows 
only  normal  conditions.  But  in  multiple  meta- 
stases  there  are  signs  of  abnormal  activity  in  the 
bone  marrow,  i.e.,  leucocytosis  in  the  form  of 
polynucleosis  and  myelocytosis,  nuclear  red  blood 
corpuscles.  Later  on  regeneration  of  the  mar- 
row ceases,  the  marrow  elements  are  wanting  in 
the  blood,  whole  colonies  of  atypical  marrow 
cells  are  found  in  it.  A  careful  X-ray  exam- 


41U  GENERALIZED   PAIN 

inafion  of  the  whole  bony  framework  should  be 
made  in  all  cases.  The  differential  diagnosis 
will  not  be  concerned  with  these  points  when 
multiple  osseous  metastases  are  due  to  an  or- 
dinary, benign,  adenomatous  or  insignificant 
struma.  But  note,  that  a  malignant  struma  may 
manifest  the  clinicl  symptoms  of  hyperthy- 
reoidism. 

The  pains  caused  by  these  metastases  are  par- 
ticularly distinguished  by  their  fleeting,  capric- 
ious character:  today  they  are  felt  in  one  place, 
tomorrow  in  another;  now  they  torment  the 
patient  only  to  vanish  again  later  on.  This  often 
enough  leads  to  the  erroneous  diagnosis  of  rheu- 
matism, gout  or  hysteria,  especially  in  cachectic 
or  nervous  persons.  Leucocytosis  demonstrable 
in  the  blood  is  of  great  help  in  the  diagnosis, 
although  in  many  cases  the  blood  picture  is  quite 
normal.  I  again  refer  the  reader  to  the  neces- 
sity of  a  studious  X-ray  examination  of  the 
patient. 

Sarcoma  and  principally  hypernephroma  are 
further  instigators  of  multiple  metastases  of  the 
bones  with  and  without  pain  and  pulsation.  If 
they  are  present  they  may  even  arrive  before 
the  tumor  becomes  manifest.  If  a  local  swelling 
already  exists  on  the  bone,  the  diagnosis  is  made 
the  easier,  although  mistakes  are  not  always 
avoidable. 

In  hypernephroma  the  metastases  may  again 


BONES  411 

be  of  a  truly  fleeting  character,  rheumatic-like 
as  it  were,  changing  their  locality  constantly, 
before  the  clinician  is  enabled  to  recognize  a 
change  in  the  bones  or  a  primary  tumor  in  the 
kidney.  Radiology  is  a  conditio  sine  qua  non 
here  also. 

The  presence  of  a  tuberculous  hearth  in  the 
organism  is  also  likely  to  mislead  the  attending 
physician  in  his  diagnosis,  but  let  us  remember 
that  it  is  very  risky  to  believe  that,  because  there 
is  a  tuberculous  condition  in  one  organ,  morbid 
conditions  in  another  organ  of  the  same  body 
must  of  necessity  also  be  of  a  tuberculous  char- 
acter. 

There  are  other  proliferations  attributed  by 
some  authorities  to  affections  of  the  bones,  by 
others  to  systemic  diseases,  which  cause  pains, 
similar  to  those  described  in  the  foregoing  pages. 
In  most  of  these  cases  the  complaint  is  of  very 
severe  pains  in  the  nape  of  the  neck,  in  the  chest, 
the  back  and  shoulders,  sometimes  also  in  the 
limbs.  They  are  sharpened  by  physical  move- 
ments and  come  on  in  periodic  attacks.  There 
is  local  tenderness  in  the  spinal  column  or  in  one 
rib  or  another.  Later  on  softness  of  the  bones 
sets  in,  deformities  in  the  upper  spine  and  in 
the  thorax  generally,  together  with  kyphosis  are 
found.  The  sternum  becomes  prominent  owing 
to  angular  curving  of  the  ribs  through  multiple 
spontaneous  fractures.  The  chin  is  pushed  down 


412  GENERALIZED   PAIN 

on  the  chest  as  in  senile  osteomalacia  with  which 
multiple  myeloma  of  the  bones  has  so  many 
other  conditions  in  common.  This  latter  disease 
chiefly  affects  the  cranial  bones  but  avoids  those 
of  the  pelvis  and  of  the  extremities. 

The  differentiation  is  not  difficult  so  long  as 
protuberances  on  the  affected  bones,  or  multiple 
tumors  on  the  cranial  bones  (erroneously  also 
called  atheroma)  are  in  evidence.  When  these 
are  missing,  doubts  may  arise.  But  the  X-ray 
and  a  test  of  the  urine  for  Bence-Jones  albumin 
which  is  hardly  ever  present  in  osteomalacia,  will 
clear  the  situation.  Moreover,  in  osteomalacia 
the  extremities  are  nearly  always  curved  when 
the  trunk  is  markedly  affected,  whilst  in  mye- 
loma the  changes  in  the  trunk  and  skull  are  much 
less  pronounced.  If  fever  is  present  it  speaks 
for  myeloma. 

Whether  we  are  confronted  by  a  primary 
myeloma  or  a  secondary  metastatic  carcinoma 
of  the  bones  when  we  find  a  primary  organic 
neoplasm  in  the  place  mentioned  before,  the 
diagnosis  is  self-evident.  The  presence  of  Bence- 
Jones  albumin  points  to  myeloma  although  this 
albumin  is  also  found  in  multiple  metastases  of 
the  bones.  When  the  pains  are  felt  only  in  the 
extremities  or  less  markedly  so  than  in  the  thor- 
acic region  we  have  little  reason  to  think  of 
myeloma.  The  condition  of  the  blood  should 
be  of  some  help  as  in  myeloma  it  generally 


BONES  413 

shows  only  anemic,  rarely  leucemic  conditions, 
although  myelocytes  are  sometimes  found  also. 
It  is  further  of  importance  to  remember  that, 
clinically  speaking,  demonstrable  metastases  in 
the  internal  organs,  including  the  lymphatic 
glands — unless  they  are  highly  regional — never 
originate  from  myelomata.  The  presence  of 
such  metastases,  especially  in  the  glands,  con- 
sequently favors  the  assumption  of  secondary 
metastatic  neoplasms.  I  do  not  wish  to  contend, 
however,  that  a  post  mortem  may  not  reveal 
analogous  growths  in  the  bones  in  cases  of  mye- 
loma. 

On  the  other  hand  we  come  across,  occasion- 
ally, primary,  multiple,  benign  or  relatively  be- 
nign (osteoma,  osteochondroma,  echinococcus 
cysts,  or  cysts  in  the  bones  in  fibrous  ostitis) 
and  malignant  tumors  of  the  bone  marrow,  e.g., 
in  the  vertebras,  ribs,  thighs,  upper  arms,  either 
in  the  shape  of  osteosarcomata,  lymphosarcomata 
or  giant  cell  sarcomata.  They  are  all  accom- 
panied by  pains  in  the  bones  and  by  anemia, 
cachexia,  if  not  by  recurrent  fever.  The  Bence- 
Jones  albumin  may  be  found  in  this  disease  and 
its  presence  be  taken  as  a  sign  of  myeloma. 

Painful  swellings  are  also  found  in  typical 
ieucemic  lymphadenitis  and  thus  simulate  a  mye- 
loma. The  clinical  aspect  and  the  condition  of 
the  blood  should  suffice  for  a  proper  diagnosis. 

Syphilitic  or  tuberculous  multilocular  osteo- 


414  GENERALIZED   PAIN 

periostitis  are  here  within  the  reach   of  possi- 
bilities. 

In  recent  syphilitic  periostitis  and  true  gum- 
matous  osteoperiostitis  we  find  new  growths  in 
the  form  of  painful,  if  not  painless,  round  tumors 
of  various  size.  They  are  more  or  less  hard,  i.e., 
of  a  fluctuating  consistency  and  mostly  situated 
on  those  bones  which  are  less  protected  by  tissue, 
I  mean  the  skull,  the  forehead,  the  clavicles,  the 
sternum,  the  ribs  and  the  inner  side  of  the  tibiae. 
The  diagnosis  is  not  hard  to  make  because  the 
usual  symptoms  of  secondary  syphilis  are  always 
manifest,  not  to  speak  of  their  nocturnal  char- 
acter. And  again,  in  recent  cases  of  osteoperi- 
ostitis we  find  very  little,  if  any,  local  reddening 
of  the  skin,  unless  it  is  due  to  some  mechanical 
irritation;  we  also  can  notice  that  the  swellings 
are  flat  in  shape  and  gradually  recede,  while 
in  gummatous  ostitis  necrosis,  ulceration  and 
subsequent  scarification  of  the  bones  obtain.  It 
is  worth  while  to  remember  that  gummatous 
periostitis  manifests  itself  in  the  form  of  a 
diffuse  and  not  circumscribed  infiltration  which 
breaks  down  in  an  ulcerous  state.  Minor  flat 
and  far-reaching  enlargements  of  the  bones  are 
also  demonstrable.  Likewise  that  gummatous 
ostitis,  e.g.,  in  the  clavicles,  or  in  the  fingers  or 
forearm  is  apt  to  lead  to  spontaneous  fractures 
On  the  long  bones  and  on  the  skull  it  may  cause 
proliferation  and  subsequent  thickening  of  the 


BONES  415 

bones,  on  the  skull  also  hyperostosis  or  leontiasis 
ossea. 

Secondary  syphilis  does  not  as  a  rule  cause 
swellings  in  the  bones,  but  rather  transient,  re- 
current inflammations  and  moderate,  not  strictly 
localized  and  wandering  pains.  The  patient  is 
wont  to  call  them  "rheumatics."  The  fact  that 
they  are  sharper  in  the  night  time,  other  char- 
acteristic symptoms  and  the  Wassermann  reac- 
tion should  influence  the  opinion. 

In  recent  syphilitic  osteoperiostitis  we  find  the 
same  fluctuations  in  the  body  temperature  that 
are  characteristic  of  secondary  luetic  conditions, 
while  in  the  gummatous  form  a  normal  degree 
prevails  unless  pus  cells  are  present. 

If  children  are  affected  in  this  manner  heredi- 
tary syphilis  suggests  itself.  In  hereditaria 
tarda  the  first  four  to  five  years  in  the  patient's 
life  pass  by  without  morbid  symptoms.  It  is 
at  a  later  date,  sometimes  even  beyond  the  stage 
of  puberty,  that  the  characteristic  manifesta- 
tions on  the  bones  make  their  appearance.  The 
history  of  the  case,  Hutcliimoris  teeth,  saddle 
nose,  remnants  of  former  peranchymatous  kera- 
titis,  partial  deafness,  chronic  swellings  of  the 
glands  and  knee  joints,  are  all  typical  road  signs, 
especially  if  the  Wassermann  is  not  neglected. 

Tuberculous  ostitis  and  also  osteomyelitis  may 
affect  one  or  more  bones  at  the  same  time.  In 
both  rising  temperature  is  usual. 


416  GENERALIZED   PAIN 

In  the  first  named  disease  fever  is  moderate, 
if  not  absent,  although  there  is  local  tenderness, 
the  pains  are  not  severe,  but  there  are  functional 
disturbances,  for  instance,  if  it  attacks  one  of 
the  lower  extremities  the  patient  is  forced  to 
limp.  Its  tuberculous  genesis  may  be  recog- 
nized from  a  tuberculous  state  seen  in  other 
organs,  from  the  nature  of  existing  tumors 
which  are  of  a  livid  color,  the  thin,  cheesy  pus, 
the  slack,  yellowish  granulations  of  the  fistulas, 
and  last  but  not  least,  from  the  Roentgen  pic- 
ture. It  is  of  interest  to  know  that  this  disease 
has  a  preference  for  the  small  hollow  bones  such 
as  the  metacarpal,  metatarsal  and  phalangeal 
bones  (spina  ventosa).  In  the  larger  bones  it 
settles  rather  in  the  diaphyses,  rarely  in  the  epi- 
physes,  which  fact  distinguishes  it  from  acute 
purulent  osteomyelitis. 

With  the  assistance  of  laboratory  blood  tests 
and  the  Roentgen-ray  the  diagnosis  of  this  dis- 
ease can  be  made  from  the  following  symptoms: 
the  initial  stages  show  chills  and  high  fever,  a 
marked  general  indisposition,  diarrhea,  typhoid 
state,  soon  to  be  followed  by  severe  pains  around 
the  heads  of  the  affected  bones  (shin  bone,  thigh, 
upper  arm,  sometimes  the  lower  arm,  clavicles, 
ribs  and  the  short  hollow  bones),  local  reddening 
of  the  skin,  higher  local  temperature,  collateral 
edema,  later  on  septico-pyemic  generalized  in- 
fection. While  tuberculous  ostitis  may  be  of 


BONES  417 

an  acute  character  with  high  fever  throughout 
its  course,  purulent  osteomyelitis  is  generally 
subacute  or  chronic  in  its  nature  and  the  patient 
suffers  from  rheumatoid  pains  in  the  affected 
parts,  and  even  from  minor  functional  disturb- 
ances, for  many  a  year.  When  a  differential 
diagnosis  from  neoplasms,  syphilis  or  tubercu- 
losis tests  will  furnish  the  required  information. 
Marked  leucocytosis  points  to  osteomyelitis;  in 
tuberculous  ostitis  a  mixed  infection  does  not 
exist. 

Albuminous  periostitis  is,  so  to  speak,  an 
intermediary  disease  between  purulent  osteomye- 
litis and  tuberculous  ostitis.  It  sets  in  gradually 
with  little  or  no  fever,  is  mostly  chronic  in  char- 
acter (sometimes  acute  in  the  beginning  with 
fever)  and  localized  in  the  same  bones  as  in 
acute  osteomyelitis  and  also  at  the  ends  of  the 
epiphyses,  sometimes  associated  with  osteomye- 
litis in  other  bones,  local,  well  defined,  elastic, 
fluctuating  swellings  which  secret  a  stringy,  al- 
buminous, synovia-like  fluid  between  the  perios- 
teum and  the  coating  of  the  long  bones  showing 
traces  of  tubercle  bacilli  or  strepto-  or  staphy- 
lococci. 

I  add  two  relatively  rare  forms  of  unilocular 
or  multiple  acute  or  chronic  osteoperiostitis,  viz., 
acute  or  chronic  osteoperiostitis  malleosa  and 
actinomycotica.  The  former  is  easy  to  recognize 
if  it  occurs  in  a  case  of  positive  glanders,  because 


418  GENERALIZED   PAIN 

it  is  merely  a  manifestation  of  pyemia  of  the 
bones.  In  chronic  farcy  the  diagnosis  meets 
with  some  difficulties.  The  salient  features  which 
require  consideration  are:  does  the  patient  come 
in  contact  with  horses  or  other  animals  subject 
to  glanders,  the  presence  of  typical  sores  in  the 
nose  and  skin,  of  abscesses  in  the  muscles  or  in 
the  periarticular  tissue  (a  subacute  or  chronic- 
exudative  articular  rheumatism  might  be  simu- 
lated by  the  latter  condition),  sub-febrile  or 
slightly  febrile  temperature,  a  positive  diazo- 
reaction  and  bacteriologic  findings. 

Actinomycotic  osteoperiostitis  or  osteomyelitis 
is  mostly  of  a  secondary  character  and  arises 
from  a  continuity  in  a  vertebra,  rib  or  in  the 
sternum,  but  it  may  also  make  its  appearance 
in  a  long  bone,  e.g.,  in  the  thigh  after  a  trauma, 
with  local  swelling  and  all  the  symptoms  of  an 
acute  osteomyelitis.  When  it  runs  an  acute 
course  it  is  very  likely  of  metastatic  origin. 

Typhoid  osteoperiostitis  generally  sets  in  dur- 
ing the  period  of  convalescence  from  typhoid, 
principally  in  the  tibia,  also  in  the  ribs,  the 
sternum,  clavicles,  etc.  It  may  be  purulent,  but 
is  as  a  rule  reconstructive  in  character.  The 
etiologic  diagnosis  may  meet  with  difficulties  if 
the  symptoms  have  been  overlooked  or  the  pri- 
mary infection  is  of  very  old  standing.  Blood 
tests  are  necessary. 

Malta  fever  may  also  produce  suppuration  of 


BONES  419 

the  bones  and  an  abscess  in  a  dependent  part. 
The  diagnosis  depends  on  the  possibility  of  an 
infection,  the  examination  of  the  pus  and  the 
presence  of  the  micrococcus  militensis. 

Acute  articular  rheumatism  may  cause  the 
formation  of  various  forms  of  periostitis,  for 
instance,  the  initial  acute  rheumatic  form,  in 
which  very  severe  pains,  swelling,  reddening  of 
the  skin  and  high  fever  are  noticed. 

Paget's  ostitis  must  again  be  mentioned.  In 
the  beginning  it  is  an  individual  disease  of  the 
skull,  or  tibia,  femur  or  spinal  column,  but  has 
also  been  observed  on  the  clavicle  and  ribs.  It 
is  a  painful,  sometimes,  however,  indolent  affec- 
tion of  the  bones  which  gradually  involves  the 
whole  thoracic  frame  if  not  also  the  pelvis. 

The  patient  complains  of  rheumatoid  pains  in 
the  affected  bones  strongly  influenced  by  weather 
conditions,  difficulty  and  clumsiness  in  walking. 
The  progress  of  the  disease  is  assymmetric 
throughout.  The  head  grows  larger  and  larger 
and  leans  forward  until  the  chin  touches  the 
chest,  the  cervical  and  thoracic  vertebrae  become 
kyphotic,  the  thorax  looks  shortened  with  the 
lower  part  expanded  and  separated  from  the 
abdomen  by  a  deep  furrow,  the  extremities  are 
curved,  the  knees  approximate  each  other,  and 
the  affected  bones  are  abnormally  thick,  although 
motation  is  seemingly  little  impaired.  The 
X-ray  materially  assists  the  diagnosis. 


420  GENERALIZED   PAIN 

We  will  now  consider  the  differential  diag- 
nosis between  acromegaLy,  Paget's  ostitis  and 
hyperostitis,  since  each  of  them  involves  the 
enlargement  of  the  head. 

Acromegaly  is  distinguished  not  only  by  the 
unusual  expansion  of  the  head,  but  also  by  the 
symmetrical,  uniform  enlargement  of  the  arms 
and  legs  (bones  and  tissues  as  well)  and  ab- 
normal bulkiness  of  the  hypophyses.  Mark  the 
symmetrical  progress  of  the  disease  as  against 
the  asymmetry  prevailing  in  Paget's  ostitis,  and 
again  that  in  hyperostitis  the  distension  of  the 
head  is  diffuse  and  not  tumorlike.  But  when 
it  is  tumorous  the  various  growths  are  concati- 
nated,  but  each  prominence  has  its  own  indi- 
vidual circumference;  moreover,  they  attack  in 
the  first  line  the  bones  of  the  face,  whilst  in 
Paget's  ostitis  these  remain  unmolested  or  near- 
ly so;  furthermore,  Paget's  ostitis  presents  a 
smooth  surface  all  over  the  growth.  Besides, 
in  hyperostitis  we  find  exophthalmos  and  paral- 
ysis of  the  cerebral  nerves,  which  is  not  the 
case  in  the  other  disease.  But  this  latter  nearly 
always  involves  the  bones  of  the  lower  extremi- 
ties, quite  an  exception  in  hyperostitis,  which, 
moveover,  occurs  chiefly  in  youthful  individuals 
when  Paget's  ostitis  prefers  old  age. 

Gummatous  ostitis  may  be  confused  with  Pa- 
get's ostitis  because  it  also  leads  to  scleroting 
conditions  which  would  enlarge  the  head  con- 


BONES  421 

siderably.  If  it  is  of  syphilitic  origin  it  can 
easily  be  separated  from  Paget's  ostitis  by  the 
typical  symptoms  and  the  Wassermann  reac- 
tion, unless  both  are  of  a  luetic  character. 

There  is  a  peculiar  aspect  to  Paget's  ostitis, 
viz.,  very  often  the  neoplasms  of  different  local- 
ization, e.g.,  endothelioma  of  the  pleura,  gastric 
or  hepatic  carcinoma,  likewise  neoplasms  of  the 
bones,  such  as  sarcoma  of  the  tibia,  enchondroma 
of  the  pelvis,  are  associated  with  it.  Thus  we 
may  be  tempted,  when  we  see  the  patient  only 
in  the  last  stadium  of  the  disease,  to  ascribe  the 
whole  symptom  complex  direct  to  the  neoplasm 
and  its  metastases.  But  the  anamnesis  and  rela- 
tively long  duration  of  the  affection,  the  well- 
nourished  physical  appearance  of  the  patient 
and  his  fit  condition,  also  the  smooth  surface  of 
the  enlargement  all  over  the  head  and  the  curves 
in  the  lower  extremities,  together  with  the  Roent- 
gen picture  should  prove  sufficient  evidence  in- 
sofar as  the  diagnosis  is  concerned. 

To  differentiate  Paget's  ostitis  from  osteo- 
malacia  serulis  is  not  always  such  an  easy  matter, 
because  in  both  very  intensive  pains  are  endured 
and  in  both  the  body  shrinks  in  height.  But  in 
osteomalacia  the  thorax  is  principally  involved, 
while  the  head  and  the  lower  extremities,  espe- 
cially the  long  bones,  remain  intact,  or  if  the 
bones  are  at  all  affected  the  changes  are  sym- 
metrical in  form,  while  in  ostitis  the  progress  is 


422  GENERALIZED   PAIN 

irregular  and  asymmetrical  in  form  and  the 
head  is  very  much  deformed.  Here  again  the 
X-ray  shows  the  differentiation  in  a  marked 
fashion. 

Furthermore,  a  differential  diagnosis  may 
have  to  be  made  between  fibrous  ostitis  (Reck- 
linghausen's  disease)  and  the  two  aforementioned 
affections  on  account  of  the  intensive  "rheu- 
matic" local  pains  and  the  bending  of  the  bones. 
In  Recklinghausen's  disease  we  can  notice 
fibrous  changes  in  the  bone  marrow,  with  spongy 
alterations  in  the  bone  tissue  and  the  formation 
of  giant  cell  sarcomata  and  spindlelike  swellings 
around  the  metaphyses,  along  the  long  bones, 
with  parchment  crackling  and  fluctuation,  also 
infractions,  if  not  fractures,  of  the  bones.  We 
must  resort  to  the  Roentgen-ray  once  more. 

I  must  refer  here  to  still  another  disease 
which  I  have  purposely  avoided  to  mention  thus 
far  because  it  is  in  reality  not  a  primary  affec- 
tion. I  mean  "osteoarthropathie  hypertrophi- 
ante  pneunuque"  with  drumstick  fingers  and  its 
intermediary  form,  i.e.,  Bamberger's  disease 
with  osteoperiosteal  enlargements  of  the  long 
bones,  especially  at  their  distal  ends  in  the  thighs 
and  forearms. 

I  confine  myself  to  the  two  principal  forms. 

Bamberger's  combination  type  is  character- 
ized by  drumstick  fingers  and  parrot-beak  nails, 
spontaneous  and  sensitive  swellings  in  the  distal 


BONES  423 

zones  of  the  forearms  and  the  lower  thigh  bones. 
Around  the  radius  and  malleolus  we  find  dis- 
tinct enlargement  and  the  middle  of  the  hand 
appears  plumper.  The  X-ray  and  anatomical 
examination  show  still  more  changes  in  the 
shape  of  inflammatory  periosteal  growths. 

In  osteoarthropathie  hypertrophiante  the  fin- 
gers are  shaped  like  drumsticks  whilst  the  hand 
itself  is  shaped  more  in  the  form  of  a  paw,  the 
feet  are  very  much  deformed,  the  whole  distal 
surroundings  of  the  lower  thigh  and  forearm 
are  swollen,  and  similar  enlargement  may  be 
observed  in  the  sternum,  the  ribs,  clavicles  and 
pelvis.  Kyphoscoliosis  also  accedes  in  some 
cases. 

From  this  short  sketch  it  will  be  seen  that 
osteoarthropathie  hypertrophiante — I  shall  speak 
about  its  diagnostic  importance  later  on — pos- 
sesses a  certain  resemblance  to  acromegaly.  Yet 
a  mistake  between  these  two  diseases  can  be 
easily  prevented.  I  will  not  speak  here  of  the 
secondary  nature  of  osteoarthropathie  (see  later 
on  about  drumstick  fingers),  but  only  of  other 
phases  which  distinguish  this  disease  from  acro- 
megaly. In  the  former  the  fingers  are  shaped 
like  drumsticks  and  the  nails  like  a  parrot's 
beak;  in  acromegaly  they  are  harmoniously  en- 
larged in  every  dimension,  though  the  finger 
nails  are  comparatively  small.  In  osteoarthro- 
pathie the  hands  and  feet  are  misshapen  like 


424  GENERALIZED   PAIN 

paws;  in  acromegaly  they  are  enormously,  but 
symmetrically,  enlarged,  not  deformed.  The 
bony  deposits  and  protuberances  on  the  distal 
ends  of  the  long  bones  so  typical  of  osteoarthro- 
pathie  are  missing  in  acromegaly.  The  swelling 
of  the  overlying  tissues,  the  enlargement  of  the 
hypophyses  and  all  the  other  characteristic  symp- 
toms of  acromegaly  are  missing  in  osteoarthro- 
pathie.  A  combination  of  the  two  diseases  has 
been  reported  in  one  case. 

There  is  a  case  of  bone  disease  on  record 
which  is  ascribed  to  intestinal  troubles.  The 
patient  suffered  since  early  childhood,  but  with 
periodical  interruptions,  from  diarrhea,  appar- 
ently due  to  a  toxic  decay  of  albumin  in  the 
bowels.  By  avoiding  meat  and  other  albumin- 
ous foodstuffs  the  patient  was  cured.  What  is 
of  interest  from  the  clinical  standpoint  is  the 
fact  that  the  symptoms  had  much  in  common 
with  acromegaly  and  Pagefs  ostitis.  At  times 
they  simulated  those  of  Marie's  osteoarthropathie 
hypertrophiante,  or  showed  rachitic  characteris- 
tics. The  patient  complained  of  abnormal  fa- 
tigue, and  at  times  of  pains  in  the  bones  and 
joints.  Swellings,  enlargements  and  deformi- 
ties were  also  observed  in  the  bones. 

There  are  a  few  other  affections  of  the  bones 
in  which  local  pain  is  a  prominent  symptom. 
As  they  are  of  minor  significance  for  the  differ- 
ential diagnosis  I  will  only  mention  them.  Noth- 


BONES  425 

nagel's  lymphadenia  ossium,  is  not  as  yet  prop- 
erly classified,  although  it  seems  to  bear  the 
character  of  a  leucemic  lymphomatosis.  Bruck's 
disease  is  typified  by  enormous  contortion  in  the 
bones  and  frequent  fractures  thereof,  also  by 
multiple  ankylosis  of  the  joints  and  by  muscular 
atrophy.  Then  there  is  Ziegler's  osteotabes  in- 
fantum,  and  another  childhood  disease,  i.e.,  os- 
teogenesis  imperfecta  tarda, 

Some  of  the  morbid  conditions  mentioned  in 
the  foregoing  pages,  such  as  acromegaly,  are  in 
reality  not  primary  affections  of  the  bones;  and 
there  is  still  a  number  of  others  belonging  to 
this  category  in  which  likewise  pain  in  the  bones 
plays  a  significant  role,  although  a  primary 
disease  of  the  bones  does  not  exist.  Among 
them  are  the  following: 

In  degeneratio  adiposo-genitatis  arising  from 
hypopituitarism,  periodic  spontaneous  pains  in 
the  ribs  and  extremities  are  felt,  although  from 
a  diagnostic  standpoint  they  are  not  of  the  same 
importance  as  in  acromegaly. 

Such  local  spontaneous  pains  are  not  uncom- 
mon in  scurvy  in  the  adult,  when  hemorrhages 
set  in  between  the  bones  and  the  periosteum, 
and  in  Barlow's  disease  ( a  combination  of  scurvy 
and  rickets).  The  children  cry  out  loud  upon 
being  merely  touched. 

If  the  patient  complains  of  so-called  "rheu- 
matic" pains  which  increase  in  violence  when  he 


426  GENERALIZED   PAIN 

moves  about  or  is  dressing,  it  is  a  reminder  of  a 
primary  disease  of  the  blood  or  of  the  blood- 
producing  organs,  viz.,  acute  or  chronic  myeloid 
leucemia,  aleucemia  and  myeloid  chloroma,  but 
also  (in  a  minor  degree)  lymphatic  leucemia,  in 
which,  as  a  rule,  only  sensitiveness  on  pressure 
prevails  in  the  bones.  Pernicious  anemia  (ane- 
mia aplastica,  thrombopenia)  and  Jack's  disease 
(see  "Articular  Pains")  deserve  a  place,  too. 
The  subjective  sensation  is  here  restricted  rather 
to  a  dull  sensitiveness  in  the  bones  similar  to 
that  in  some  cases  of  chlorosis,  but  local  pressure 
or  percussion  of  the  bones  elicit  most  intensive 
pain.  A  combination  of  myeloid  leucemia  and 
osteomalacia  is  on  record. 

Pains  in  the  bones  and  accompanying  swelling 
of  the  lymphatic  glands  which  occur  in  extirpa- 
tion of  the  spleen  are,  no  doubt,  due  to  over- 
activity  forced  upon  the  bone  marrow  by  the 
missing  splenic  function. 

I  will  add  here  an  observation  from  my  own 
practice  which  may  interest  the  reader.  I  have 
seen  girl  patients,  before  and  during  the  stage 
of  puberty,  who  complained  of  abnormally  quick 
fatigue  and  also  of  pains  in  the  joints  or  in  the 
tibia?,  with  pronounced  tenderness  on  percussion 
in  the  bones,  and  even  in  the  thighs.  I  could 
find  no  other  explanation  than  an  abnormally 
quick  development  of  the  body.  This  physical 
growth  seemed  to  come  on  in  regular  spells, 


BONES  427 

one  after  the  other  in  quick  succession,  and  with 
each  the  pains  in  the  bones  would  arrive,  only 
to  disappear  when  nature  had  finished  its  task. 
Noteworthy  changes  in  the  condition  of  the  blood 
I  was  never  able  to  observe. 

Pains  in  the  bones,  particularly  in  the  frame 
of  the  chest,  and  very  hard  to  distinguish  from 
intercostal  neuralgia,  are  often  enough  part  of 
the  symptoms  in  the  climacterium.  If  we  con- 
sider the  age  and  sex  of  the  patient,  the  waning 
function  of  the  ovaries,  the  general  gynecologi- 
cal conditions  and  other  climacteric  disorders, 
above  all  vasomotoric  disturbances  (flushing  of 
the  face,  sweats,  -paresthesias  of  the  extremities, 
swooning  spells,  palpitation  of  the  heart,  angi- 
noid  attacks),  accumulation  of  adipose  tissue, 
Heberden"s  nodes,  etc.,  the  diagnosis  could  not 
go  amiss,  and  yet  it  will  be  wise  to  keep  a  sharp 
eye  on  the  possible  development  of  a  tardy 
osteomalacia. 

The  Wolhywan,  or  five  days  fever,  which  be- 
came common  during  the  World's  War,  requires 
some  attention  here.  Both  names  are  badly 
chosen,  because  it  did  not  exactly  originate  in 
Wolhynia,  neither  is  it  recurrent  in  five-day 
periods;  only  in  rare  cases  so.  Still  it  has  the 
character  of  recurring  four  or  five  times  at 
irregular  intervals,  and  is  generally  associated 
with  a  tumor  of  the  spleen,  and  also  with  osteo- 
periosteal  neuralgic  pains. 


428  GENERALIZED   PAIN 

Tibial  pains  are  observed  in  abdominal  ty- 
phoid, influenza  and  spotted  typhus.  They  may 
even  degenerate  into  generalized  pains  of  the 
bones,  as  is  also  the  case  in  paratyphoid  and 
recurrent  fever,  and  sometimes  in  typhoid  vac- 
cination. When  they  occur  in  erythema  nodo- 
sum,  a  wrong  diagnosis  of  osteomyelitis  may 
result. 

If  spontaneous  pains  arise  in  gout,  they  are 
of  a  minor  degree,  but  very  severe  on  percussion, 
especially  on  the  condyles  of  the  humerus,  the 
head  of  the  radius,  in  the  os  calcaneum,  and  in 
the  small  tarsal  bones,  but  not  more  acute  in 
the  night  time. 

Certain  exogenous  poisons  may  cause  pains 
in  the  bones.  I  do  not  refer  to  the  phosphorous 
necrosis  of  the  lower  jaw  or  of  the  nose  caused 
by  chromic  acid  poisoning  (the  latter  resembling 
a  syphilitic  defect  of  the  septum),  but  to  acute 
intoxications  from  arsenic  and  phosphorus.  Al- 
though the  pains  are  rarely  spontaneous,  pres- 
sure and  percussion  evince  them  sharply  in 
the  bones,  chiefly  in  the  ribs,  the  vertebras  and 
the  tibiffi,  and  according  to  my  own  experience, 
constitute  a  frequent  and  diagnostically  most 
important  symptom.  They  are,  no  doubt,  due  to 
overactivity  of  the  bone  marrow  which,  in  acute 
poisoning  from  phosphorus,  manifests  itself  in 
the  form  of  severe  polycythemia  and  leucocy- 


BONES  429 

tosis  with  an  increase  of  the  bone  marrow 
elements. 

In  mercurial  poisoning  similar  pains  are  ob- 
served. This  is  interesting  from  the  standpoint 
of  the  differential  diagnosis  in  syphilis  and  mer- 
cural  intoxication.  Chronic  arsenic  poisoning 
belongs  here,  also.  Lancinating  pains  in  the 
bones  are  not  uncommon  in  tabes. 

Pains  which  in  their  nature  are  not  spontane- 
ous, but  provoked  by  pressure  or  percussion,  are 
of  diagnostic  value  in  a  series  of  affections  such 
as:  diseases  of  the  blood,  leucemia,  aleucemia, 
pernicious  anemia,  chlorosis,  acute  hemolytic 
anemia,  v.  Jacksch's  disease,  various  forms  of 
severe  secondary  anemia,  especially  after  neo- 
plasms (red  bone  marrow),  some  cases  of 
chronic  osteomyelitis,  and  all  the  initial  stages 
of  the  aforementioned  disorders.  In  some  cases 
of  Basedow's  disease  I  have  been  able  to  ob- 
serve in  the  bones  a  very  marked  sensitiveness 
on  pressure  or  percussion  when  a  demonstrable 
anemia  or  overstimulated  activity  of  the  bone 
marrow  were  not  present,  not  even  when  a 
complicating  osteomalacia  set  in  or  signs  of 
abnormal  softening  of  the  bones  were  in  evi- 
dence. 

In  pulmonary  emphysema  the  pains  are  of  a 
rheumatoid  nature,  especially  in  the  bones  of 
the  lower  extremities.  The  tibiae  are  most  sensi- 
tive on  pressure  and  percussion.  The  pains  are 


430  GENERALIZED   PAIN 

unmistakably  due  to  periostitic  growths  at  the 
distal  ends  of  the  tibiae,  and  remind  one  of  the 
osseous  changes  described  by  E.  Bamberger. 

In  certain  infectious  diseases,  sensitiveness  on 
pressure  and  percussion  (sometimes  rather  vague 
and  quite  indefinite),  and  also  pain  in  the  bones, 
will  be  found  a  very  valuable  asset  in  the 
diagnosis.  This  is  particularly  so  in  generalized 
septic  conditions  (septic  endocarditis)  and  in 
scarlet  fever. 

Pains  in  the  bones  belong  also  to  the  promi- 
nent prodromal  symptoms  of  secondary  syphilis, 
even  when  the  patient  is  not  affected  with  luetic 
periostitis.  There  are  no  local  changes  in  the 
bones  and  the  pains  disappear  with  the  cure 
of  the  exanthema. 

If  in  abdominal  typhoid  pain  and  tenderness 
in  the  bones  are  experienced,  it  may  be  the 
expression  of  an  existing  acute  osteomyelitis, 
the  more  so  when  we  find  a  local  edema  or  vivid 
coloring  of  the  skin  and  lymphangoid  striae. 

In  malaria  pain  and  tenderness  in  the  bones 
are  often  very  molesting  symptoms.  They  pre- 
vail in  the  long  bones  (tibise  in  particular),  like- 
wise in  the  cervical  and  upper  thoracic  vertebrae. 
But  they  carry  also  another  very  important 
message.  We  come  across  cases  in  which  the 
patient  may  have  suffered  from  some  kind  of 
fever,  but  to  the  best  of  his  knowledge  has  never 
had  an  attack  of  malaria  before  or  has  not  dwelt 


BONES  431 

in  a  malarial  district,  a  fact,  which  would  remove 
the  suspicion  of  a  possible  tumor  in  the  spleen. 
Moreover,  we  find  no  traces  of  other  morbid 
conditions  (unless  it  be  a  minor,  irregularly 
recurring  rise  in  the  temperature)  and  no  plas- 
modia  or  pigment  (but  mononucleosis)  in  the 
blood.  But  pressure  and  percussion  elicit  intense 
pains  in  the  bones,  especially  in  the  tibiae,  and  a 
week  or  two  later  we  are  confronted  by  a  typical 
attack  of  fever,  perhaps,  superinduced  by  the 
electric  current,  or  a  supervening  cold  or  by 
radiation  of  the  spleen.  In  such  a  case  we  are 
justified  to  assume  that  the  plasmodia  lay  hidden 
in  the  spleen  and  bone  marrow  and  have  only 
now  entered  the  blood.  It  is  my  firm  conviction 
that  a  definite  cure  of  malaria  can  never  be 
claimed  until  every  vestige  of  pressure  pain  in 
the  bones  has  disappeared. 

A  similar  sensitiveness  of  the  bones  is  also 
demonstrable  in  malarial  cachexia.  It  is  due  to 
anemia  and  changes  in  the  bone  marrow.  The 
same  conditions  prevail  in  carcinomatous  cach- 
exia and  in  tuberculosis. 

It  should  not  be  difficult  to  learn  from  the 
foregoing  dissertation  that  the  differential  diag- 
nosis of  "rheumatoid  pains"  leads  us  through  a 
very  wide  field  of  internal  medicine.  We  must 
not  only  take  into  consideration  the  rheumatic 
and  rhematoid  pains  of  the  muscles  and  joints, 
the  morbid  conditions  of  the  skin  (adipositas 


432  GENERALIZED   PAIN 

dolorosa,  neurofibromatosis,  sclerodermia) ,  a 
multitude  of  diseases  and  their  localization  in  the 
muscles,  in  the  fascia  and  in  the  ligaments,  in 
the  joints  and  in  the  bones  (gout),  affections  of 
the  arteries  and  veins  (sclerosis,  arteritis,  phle- 
bectasis),  neuralgic,  chronic  neuritic,  neurotic 
and  lancinating  pains  and  painful  rheumatic 
sensations  which  originate  from  diseases  of  in- 
ternal organs,  but  also  ailments  of  the  skeletal 
organism. 

Acromegaly,  primary  and  secondary  neo- 
plasms of  the  bones,  myeloma,  osteomalacia, 
osteoporosis,  fibrous  ostitis,  Paget's  ostitis,  de- 
forming, recent  syphilitic  and  gummatous  ostitis, 
chronic  purulent  osteomyelitis  as  well  as  Marie's 
osteoarthropatie  hypertrophiante  pneumique  in- 
cluding Bamberger's  subdivision,  all  are  irritat- 
ing factors  of  rheumatoid  pains. 

Osteopsathyrosis,  the  symptom  of  brittleness 
of  the  bones,  is  observed  in  osteoporosis,  osteo- 
malacia and  rickets,  in  primary  and  secondary 
metastatic  tumors  of  the  bones  (we  must  add 
enchondroma,  sarcoma,  echinococcus  cysts  and 
those  of  the  bones),  myeloma,  deforming,  fibrous 
and  gummatous  ostitis  and  Bruck's  disease.  It 
occurs  also  in  rare  cases  of  chronic  osteomyelitis 
and  tuberculous  ostitis.  Diseases  of  the  central 
nervous  system  such  as  tabes,  syringomyelia, 
poliomyelitis,  progressive  paralysis  and  mental 
disturbances  may  through  minor  traumatic  con- 


BONES  433 

ditions  lead  to  spontaneous  fractures.  The  inter- 
mediary cause  here  would  be  some  trophic  dis- 
turbance or  a  simple  atrophy  of  the  bone.  Base- 
dow's  disease  and  old  age  are  likewise  causative 
factors  of  osteopsathyrosis.  But  there  is  also  an 
independent  form  of  this  disease  which  is  called 
idiopathic  osteopsathyrosis  which  is  either  con- 
genital in  its  nature  or  at  any  rate  acquired  in 
childhood.  It  may  be  hereditary  (familial), 
but  there  are  also  solitary  cases  on  record.  The 
bones  are  of  very  soft  consistence  and  frequent 
fractures  ensue  which  cause  abnormal  curvatures 
and  deformities.  Hereditary  cases  are  easy  to 
diagnose.  In  acquired  cases  we  must  look  for 
rickets  or  juvenile  osteomalacia.  Syphilitic  af- 
fections of  the  ephiphyses  must  also  be  consid- 
ered. The  absence  of  syphilitic  symptoms  and 
the  X-ray  will  determine  the  differential  diag- 
nosis, especially  when  the  fractures  are  located 
in  the  shaft  of  the  bone  between  the  epiphyses 
and  not  where  the  diaphyses  and  epiphyses  meet. 
The  X-ray  also  shows  in  syphilis  a  swelling  of 
the  epiphyses,  while  in  idiopathic  osteopsathy- 
rosis there  is  only  an  apparent  thickening,  a 
proof  that  the  epiphyses  are  normal.  This  thick- 
ening is  caused  by  an  atrophy  of  the  diaphyses 
through  pericostal  dysplasia. 

Localized  isolated  or  multiple  swellings  of  the 
bones  may  be  observed  in  various  morbid  condi- 
tions, such  as  an  ordinary  callus,  the  different 


434  GENERALIZED   PAIN 

forms  of  acute  or  chronic  infectious  and  non- 
infectious  osteoperiostitis  (purulent  or  other- 
wise), primary  and  metastatic  plasmata,  mye- 
loma and  tumorous  hyperostosis. 

Sporotrichosis  is  another  malady  which  leads 
to  pericostal  and  osseal  abscesses.  It  is  not  hard 
to  diagnose  it.  We  find  multiple  papulous,  or 
vesiculous  and  pustulous  manifestations  in  the 
skin  and  mucous  membrane,  also  muscular  infil- 
trations thus  presenting  very  strongly  the  fea- 
tures of  tertiary  syphilis  or  tuberculosis.  The 
microscopic  examination  of  the  pus  showing 
absence  of  bacteria  and  the  agglutination  test 
will  give  ample  proofs  of  Schenk-de  Beurman's 
sporotrichosis.  Prompt  reaction  to  iodide  treat- 
ment is  another  good  test. 

Chloroma  is  a  disease  which  often  causes  the 
formation  of  tumors  of  the  bones,  especially  on 
the  cranium  and  on  the  sockets  of  the  eyes.  At 
the  present  time  it  is  recognized  as  a  subspecies 
of  lymphatic  myeloid  leucemia  and  is  distin- 
guished by  the  green  tint  of  the  distended  tissue. 
We  encounter  chiefly  subperiosteal  growths  com- 
posed of  lymphatic  tissue  especially  on  the  skull 
or  in  the  orbita,  sometimes  in  the  temporal  region 
or  around  the  cheek  bones.  Exophthalmos  and 
constriction  of  the  optical  nerve  are  frequent 
complications  when  the  tumor  is  localized  near 
the  visual  organs.  The  diagnosis  must  be  based 
upon  the  following  symptoms:  generally  simul- 


BONES  435 

taneous  swelling  of  several  lymphatic  glands  and 
of  the  spleen ;  regular,  perceptible  aggressiveness 
of  the  tumor  on  the  surrounding  tissue  (nerves 
and  muscles),  penetrating  even  into  the  spinal 
canal;  the  condition  of  the  blood  which  strongly 
resembles  that  in  lymphatic  or  myeloid  leucemia. 
Myeloid  leucemia  may  change  into  a  myeloid 
chloroma  when  the  proliferations  suddenly  as- 
sume an  aggressive  character  and  reach  out  from 
the  clavicullar  fossa  not  only  into  the  spinal 
canal,  but  also  into  the  face,  the  lower  jaw  and 
the  oral  cavities.  The  tonsils,  in  fact,  the  entire 
mucous  lining  of  the  mouth  look  as  if  they  were 
dyed  a  vivid  green,  even  the  blood  serum  shows 
that  color. 

In  rare  cases  of  lepra  swellings  of  the  bones 
(lepromata)  are  observed  preferably  on  the 
phalanges  of  the  hands  and  feet.  They  are 
spindleformed  and  strongly  resemble  the  spina 
ventosa  in  tuberculosis  or  syphilis.  The  diag- 
nosis should  result  from  the  presence  of  the 
lepra  bacillus  in  the  nodules  of  the  skin,  or  from 
the  appearance  of  erythematous,  hyperesthetic 
areas  on  the  skin,  from  the  existing  leprous  neu- 
ritis and  the  synchronous  affection  of  the  mucous 
membranes  of  the  nose,  the  mouth,  the  palate 
and  the  porterior  oral  cavities. 

When  we  see  fingers  formed  like  drum  sticks, 
or  nails  on  hands  and  feet  shaped  like  the  beak 
of  a  parrot,  or  like  the  crystal  of  a  watch,  we 


436  GENERALIZED    PAIN 

naturally  ask  the  question:  "What  is  the  origi- 
nating cause  of  these  deformities?"  The  answer 
to  this  question  will  also  solve  the  problem 
of  the  occurrence  and  clinical  significance  of 
Marie's  osteoarthropathie  hypertrophiante  and 
Bamberger's  disease  because  the  etiologic  genesis 
is  the  same  in  these  three  affections.  In  the 
majority  of  cases  the  underlying  cause  is  a  pro- 
longed purulent  condition  of  the  respiratory 
tract  such  as:  cavernous  tuberculosis,  chronic 
induration  of  the  lungs  with  dilatation  of  the 
bronchi,  gangrenous  pulmonary  abscess,  gan- 
grene of  the  lung  and  empyema.  Drum  stick 
fingers  occur  also  in  cystopyelonephritis  and  in 
dysentery.  For  the  differential  diagnosis  it  is 
worthy  of  mark  that  the  deformity  of  the  fingers 
is  of  a  specific  type  in  tuberculous  diseases.  In 
non-tuberculous  affections,  e.g.,  in  bronchiectasy 
the  drum  stick  form  is  very  conspicuous  and 
the  ungual  phalanges  are  short  and  thickened 
and  spherical,  while  in  tuberculosis  the  latter 
are  longer,  narrower  and  bent  more  like  a  hook. 
But  the  difference  is  not  always  so  pronounced. 

Analogous  misshapen  fingers  are  also  observed 
in  chronic  actinomycosis  of  the  lungs.  A  proper 
diagnosis  cannot  fail  to  result  from  the  bacte- 
riologic  examination  of  the  sputum  and  the 
likely  discovery  of  a  purulent  tooth. 

After  pneumonia  or  non-purulent  pleuritis 
and  also  in  influenza  similar  disfigurements  of 


BONES  437 

the  fingers  and  nails  may  be  seen,  mainly  in  the 
tissue  and  not  so  much  in  the  bones.  This  is 
also  the  case  in  chronic  icterus,  biliary  cirrhosis, 
chronic  alcoholism,  cholelithiasis,  liver  abscess, 
congenital  or  protracted  syphilis,  recurrent  ar- 
ticular rheumatism,  dilatation  of  the  stomach, 
tuberculous  peritonitis  or  severe  chronic  dysen- 
tery even  without  stenosis  or  intestinal  stagna- 
tion. 

Diseases  of  the  heart  (especially  congital  de- 
fects in  children),  acquired  vascular  affections 
of  this  organ,  chiefly  in  sclerosis  of  the  pulmo- 
nary artery,  intrathoracic  tumors  (carcinoma  or 
sarcoma  of  the  lungs),  mediastinal  tumors  (lym- 
phosarcoma  or  granuloma),  rachitie  deformities 
in  the  thorax,  tumors  of  the  parotis  or  carcino- 
mata  in  the  posterior  pharyngeal  cavities  belong 
to  this  category.  In  some  cases  of  intrathoracic 
tumors,  especially  in  aneurysm  of  the  aorta  or 
of  the  subclavian  artery  the  drum  stick  forma- 
tion is  noticeable  only  on  one  side. 

Perhaps  we  are  entitled  to  conclude  that  dis- 
turbances of  the  venous  circulation  are  the  or- 
iginating factors  of  these  deforming  processes 
which  in  other  diseases  may  also  be  caused  by 
neurogenous  influences,  for  instance,  in  syringo- 
myelia  and  neuritis. 

Whether  in  myxedema  the  affection  of  the 
thyreoid  gland  itself  or  the  concomitant  tuber- 
culous condition  of  the  lungs  is  the  causative 


438  GENERALIZED   PAIN 

element  of  these  changes  in  the  fingers,  is  a 
matter  of  speculation.  I  know  of  one  case  which 
pointed  to  a  glandular  source.  It  was  that  of 
a  woman  with  an  infantile  uterus  who  suffered 
from  pains  and  swellings  in  the  fingers  at  every 
menstrual  flow  but  only  during  this  period. 

I  may  add  here  also  sporadic  cases  of  senile 
osteoporosis  and  primary  polycythemia.  In  other 
cases  concomitant  disfigurations  of  other  parts 
of  the  body  have  been  observed,  such  as  enlarge- 
ments of  the  nose,  of  the  shoulders  or  the  lips, 
also  diastasis  of  the  teeth,  abnormal  growth  of 
the  hair  of  the  head,  glycosuria,  polyuria  and 
polydypsia,  also  loss  of  the  sexual  powers.  These 
changes  are  possibly  due  to  either  an  anatomical 
or  toxic  affection  of  the  hypophysis.  The  sub- 
ject is  worth  further  detailed  study. 

The  peculiarly  shaped  finger  nails  mentioned 
above  may  also  be  of  hereditary  origin,  familial 
landmarks  as  it  were. 

It  is  meet  that  I  speak  here  of  certain  morbid 
processes  which  do  not  take  place  primarily  in 
the  skeletal  system  and  yet  have  a  certain  affinity 
to  acromegaly  because  their  symptoms  are  to 
be  found  in  the  soft  parts  of  the  tissue.  But 
before  doing  so  I  will  first  mention  a  few  an- 
omalies which  are  also  due  to  abnormal  condi- 
tions in  the  bones  but  entirely  devoid  of  pain. 
For  the  purpose  of  differential  diagnosis  this 
might  appear  to  be  decisive  were  it  not  for  the 


BONES  439 

fact  that  certain  cases  of  acromegaly  develop 
also  without  painful  sensations  or  paresthesias. 

I  refer  especially  to  physiological  giantism. 
The  differentiation  between  this  and  acromegaly 
offers  no  difficulty,  because  giantism  is  not  a 
disease  but  an  abnormally  large  development  of 
all  sections  of  the  body  in  physiological  propor- 
tion. In  acromegaly  there  are  only  certain  parts 
of  the  anatomy  which  are  enlarged  in  an  unduly 
manner,  i.e.,  out  of  proportion  to  the  rest  of  the 
body,  by  a  slow  process  reaching  back  some- 
times into  the  very  period  of  childhood.  In 
many  cases  the  X-ray  does  not  show  an  enlarge- 
ment of  the  pituitary  body  (small  adenoma 
of  the  hypophysis?).  Aside  from  acromegalic 
giants  we  find  another  kind,  i.e.,  pathological 
giants,  persons  afflicted  with  tumorlike  hyper- 
ostoses,  abnormal  curvatures  of  the  bones,  e.g., 
in  rachitis,  or  with  hemihypertrophy  of  the  face, 
or  who  are  disfigured  by  hereditary  syphilis  or 
early  in  life  by  a  tumor  of  the  testicles.  Rare 
cases  as  they  are,  they  can  by  no  manner  of 
means  offer  difficulties  in  diagnosing.  The  same 
may  be  said  of  partial  giantism  or  hypertrophy 
of  particular  parts  of  the  body.  The  asymme- 
trical and  unilateral  development  of  the  morbid 
condition  and  the  complete  absence  of  all  acro- 
megalic symptoms  at  once  lead  us  to  a  positive 
finding. 

Pregnant    women— especially    in   the    second 


440  GENERALIZED   PAIN 

half  of  the  child-bearing  period — present  some- 
times a  thickening  in  the  bones  of  the  face  and 
the  arms  which  strongly  resembles  acromegaly 
(pseudoacromegaly) .  These  swellings  recede 
again  in  the  course  of  a  year  or  so.  We  may 
look  upon  them  as  an  over-activity  of  the  hypo- 
physes superinduced  by  the  altered  function  of 
the  female  genital  glands. 

In  abnormal  growth  of  the  hands  acromegaly 
is  apt  to  be  mistaken  for  syringomyelia.  In  the 
latter,  however,  the  hand  or  as  the  case  may  be, 
both  hands  are  really  deformed,  the  skin  is  thick- 
ened, the  bones  of  the  phalanges  are  enlarged, 
differently  though  in  each  finger,  the  nails  are 
unusually  small  and  shaped  like  claws. 

Moreover,  the  skin  of  the  palm  of  the  hand 
is  abnormally  thick,  there  are  painless  paro- 
nychiae  or  scars  or  defects  in  the  bones  and 
muscular  atrophies  together  with  sensibility  dis- 
turbances characteristic  of  syringomyelia  are 
present,  while  other  prominent  parts  which  un- 
dergo changes  in  acromegaly  remain  intact.  Of 
course,  a  combination  of  the  two  diseases  is  not 
among  the  impossibilities. 

Abnormal  lengthening  of  the  fingers  caused 
by  neurotic,  apparently  vasomotoric  conditions 
can  easily  be  distinguished  from  acromegaly. 

The  condition  called  cranium  progeneum  in 
which  the  lower  set  of  teeth  protrudes  beyond 
the  upper  row  may  be  a  partial  symptom  o€ 


BONES  441 

acromegaly  of  the  lower  jaw.  But  it  may  also 
be  due  to  other  morbid  processes.  It  occurs  in 
cretinism,  in  mongolism,  in  degenerates,  but 
also  in  otherwise  quite  normal  persons.  The 
differentiation  from  acromegaly  should  offer  no 
difficulties. 

In  the  child  cretinism  may  erroneously  be 
taken  for  acromegaly  as  both  have  many  symp- 
toms in  common.  But  in  cretinism  the  physical 
anomalies  are  accompanied  by  mental  defects 
and  irregularities  of  speech.  Moreover,  the 
majority  of  these  unfortunates  have  low  fore- 
heads, broad,  flat  noses,  wrinkled  faces,  promi- 
nent shoulder  bones,  deformed  knees  and  legs, 
pendulous  arms,  a  wattling  gait  and  very  thick 
skins  like  pachyderms.  With  the  observation 
of  these  symbols  and  the  aid  of  the  X-ray  the 
proper  diagnosis  can  run  no  risk. 

There  is  a  certain  similarity  between  myx- 
edema  and  acromegaly,  because  in  myxedema 
the  face  is  very  much  swollen  and  lumpy  and 
the  hands  and  feet  and  the  tongue  are  consider- 
ably enlarged.  The  patient  complains  also  of 
pain  in  the  bones.  But  it  should  not  be  hard  to 
separate  the  one  disease  from  the  other  if  we 
consider  that  in  myxedema  the  edematous  nature 
of  the  swellings  is  so  palpable.  Nevertheless, 
I  will  enumerate  here  some  of  the  distinguish- 
ing features:  the  back  of  the  hands  looks  like 
upholstery,  the  eyelids  are  swollen,  the  cheeks 


442  GENERALIZED   PAIN 

are  puffy  and  pendulous,  the  whole  face  has  a 
dull,  sleepy  expression,  mental  activity  is  re- 
tarded, the  voice  is  raucous,  the  skin  dry  and 
scaly,  the  physical  movements  are  clumsy,  the 
body  temperature  is  low  and  the  patient  com- 
plains of  feeling  cold  and  chilly,  the  hair  falls 
out,  there  is  stubborn  constipation,  the  thyreoid 
gland  is  very  small,  if  not  missing  altogether. 
If  anything  else  is  required  the  Roentgen-ray 
will  supply  the  information. 

The  absence  of  osseous  lesions  in  pachydermia 
and  elephantiasis  makes  a  separation  from  acro- 
megaly  easy.  So  far  as  habitus  scrophulosus  is 
concerned  it  is  readily  distinguished  by  the 
swollen  lips,  nose  and  eyelids.  In  rachitis  the 
resemblance  to  acromegaly  is  perhaps  more  pro- 
nounced, but  there  are  so  many  characteristic 
signs  in  this  disease  that  a  mistake  is  well  nigh 
impossible. 

There  is,  however,  a  certain  rudimentary  form 
of  acromegaly  in  which  "rheumatic"  pains  in 
the  bones  manifest  themselves  and  in  conse- 
quence should  be  mentioned  here.  I  may  be 
permitted  to  call  this  condition  "acromegaloid- 
ism."  The  hands  and  feet  and  sometimes  also 
the  nose,  ears  and  the  lower  jaw  appear  very 
much  enlarged,  in  fact  there  is  a  general  impres- 
sion of  acromegalic  symptoms,  the  cerebral  and 
genital  manifestations  are  missing.  It  is  not 
yet  definitely  known  whether  the  underlying 


BONES  443 

cause  consists  of  small  adenomata  in  the  anterior 
lobes  of  the  hypophyses  or  whether  we  are  deal- 
ing simply  with  concomitant  manifestations  of 
chronic  bronchial  affections. 

A  small,  benign,  hypophyseal  tumor  of  this 
kind  may  very  well  mask  an  attack  of  neuras- 
thenia and  be  accepted  as  such.  The  patient 
merely  complains  of  unusual  fatigue  and  in- 
termittent, headaches.  Ocular  symptoms  are 
missing  and  the  X-ray  reveals  no  abnormal 
conditions.  But  a  very  careful  and  painstaking 
examination  may  yet  disclose  lesser  enlargements 
in  the  extremities,  spacing  between  the  teeth, 
progressive  impotence  or  cessation  of  the  men- 
strual function. 

Further  details  of  the  differential  diagnosis 
of  osteomalacia  claim  some  space  in  the  present 
discussion,  because  up  till  now  I  have  separated 
this  disease  only  from  osteoporosis,  myeloma, 
rachitis  and  tumors  of  the  bones.  It  is  not  neces- 
sary to  mention  that  osteomalacia  may  upon  a 
superficial  examination  be  mistaken  for  muscular 
or  articular  rheumatism,  or  for  neuralgia  and 
even  gout.  More  difficult  is  its  differentiation 
from  arthritis  deformans  in  both  the  hip  joints, 
for  difficulty  in  walking  and  pain  in  lateral 
abduction  of  the  hip  joints  are  common  to  both 
diseases.  But  here  again  the  Roentgen-ray  will 
promptly  bring  light.  Nevertheless,  I  will  say 
that  a  careful,  slow  movement  of  the  hip  joint 


444  GENERALIZED   PAIN 

with  the  patient  in  a  recumbent  position  will 
prove  free  motility  in  cases  of  osteomalacia 
while  this  is  not  so  in  arthritis  def  ormans.  Treat- 
ment with  phosphoric  drugs  is  also  a  promising 
test,  although  good  results  with  these  same  rem- 
edies have  likewise  been  obtained  in  deforming 
arthritis. 

Senile  osteomalacia  settles  with  preference  in 
the  thoracic  bony  frame,  chiefly  in  the  spinal 
column.  In  this  case  the  differential  diagnosis 
is  a  question  of  arikylopoietic  spondylarthritis. 
The  former  is  proved  by  painful  sensations  on 
pressure  in  other  bones  apart  from  the  articula- 
tions of  the  thoracic  frame  and  by  the  X-ray. 

We  may  also  be  called  upon  to  differentiate 
between  osteomalacia  and  multiple  tertiary  syph- 
ilitic affections  of  the  bones,  especially  when  the 
pains  are  both  of  a  subjective  and  objective 
nature,  with  adductor  spasms,  increased  tendon 
reflexes  in  the  lower  extremities,  perhaps  also 
ileospasms,  and  wattling  gait.  The  presence  of 
localized  enlargements  of  the  bones,  nocturnal 
pains,  unilateral  onset  or  asymmetry  of  the 
manifestations,  the  Wassermann  reaction,  the 
Roentgen  picture  and  the  effect  of  specific 
therapeutic  measures  should  prove  determining 
factors. 

Diseases  of  the  nervous  system  must  also  be 
considered  in  this  connection.  Likewise  affec- 
tions of  the  spinal  cord  such  as  sclerosis  of  the 


BONES  445 

local  arteries.  Initial  paresthesias  are  common 
property  in  these  diseases  as  well  as  in  osteo- 
malacia,  and  so  are  local  pain  and  increase  of 
the  tendon  reflexes.  But  the  remaining  symp- 
toms such  as  tendon  clonus,  positive  Babinski, 
intermittent  dysbasia,  muscular  atrophies  and 
bladder  and  rectal  troubles  always  point  to  spinal 
arteriosclerosis. 

Spastic  spinal  paralysis  or  some  other  affec- 
tion resembling  it  are  not  unlikely  to  be  taken 
for  osteomalacia.  But  a  careful  observer  knows 
how  to  circumvent  such  a  palpable  error. 

Hysterical  pseudoosteomalacia  on  the  other 
hand  offers  greater  difficulties.  It  requires  some- 
times long  continued  and  close  observation  of 
the  patient  before  the  contrast  between  the  pains 
and  the  motoric  properties  of  the  two  diseases, 
i.e.,  osteomalacia  and  hysterical  pseudo-osteoma- 
lacia,  is  recognized.  Suggestion  and  phosphoric 
treatment  will  solve  the  problem. 


Pain  in  the  Joints 

In  the  majority  of  cases  the  patient  is  able 
to  correctly  localize  an  articular  pain.  But  it 
happens  also  that  he  will  attribute  pain  to  a 
certain  joint  when  the  real  seat  of  it  is  to  be 
found  elsewhere,  or  he  will  experience  a  painful 
sensation  in  a  place  somewhat  removed  from  the 
affected  joint. 

From  local  tenderness,  impairment  of  the 
articular  motility  and  patent  changes  in  the  joint 
the  truth  can  be  easily  learned. 

For  the  purpose  of  a  clearer  understanding 
I  divide  the  subject  into  two  groups,  viz.:  acute 
and  chronic  articular  pain. 

I.  Acute  Articular  Pain 

When  a  patient  complains  of  sudden  acute 
pains  in  the  joints  our  first  suspicion  is  natu- 
rally that  of  articular  rheumatism.  It  will  be 
confirmed  if  we  find  the  following  symptoms: 
pains  in  the  small  and  large  joints,  distal  as  well 
as  proximal,  as  a  rule  symmetrical  in  those  of 
the  extremities,  possibly  in  those  of  the  spinal 
column,  of  the  lower  jaw,  of  the  clavicle  and 
the  symphyses,  etc.,  often  synchronously  in  sev- 
eral joints  bounding  from  one  joint  to  another, 

446 


JOINTS  447 

enlargements  in  the  joints,  the  superficial  skin 
has  a  reddish,  shiny  appearance  and  is  feverish, 
rising  body  temperature,  definite  reaction  to 
salicylic  treatment,  profuse,  annoying  and  pecu- 
liarly acid  perspiration  even  before  salicylic 
drugs  have  been  administered.  Duration  of  the 
disease  three  or  four  weeks,  but  sometimes  re- 
peated recurrent  attacks  in  previously  affected 
joints.  The  heart,  especially  its  serous  coating, 
may  be  implicated  and  at  times  initial  signs  of 
a  slight,  transient  angina  are  present. 

In  children  we  are  able  to  discover  sometimes 
multiple  nodules  the  size  of  a  pinhead  or  pea 
in  the  subcutaneous  cellular  tissue  over  the 
affected  joints  of  the  extremities.  These  nodules 
feel  like  soft  cartilagenous  matter  and  are  more 
or  less  tender  upon  pressure,  the  skin  above 
them  appears  quite  normal,  at  the  utmost  only 
a  slight  tinge  of  reddening  is  perceptible.  Simi- 
lar nodes  may  be  found  in  the  tendons  or  in 
the  tendon  sheaths  or  in  the  periosteum,  spinous 
processes,  sacrum  or  in  the  galea  aponeurotica. 
This  condition  is  associated  with  endocarditis 
and  chorea.  Perhaps  an  appropriate  name  for 
it  would  be  acute  nodose  rheumatism. 

The  necessity  to  differentiate  between  acute 
articular  rheumatism  and  septic  polyarthritis  on 
the  one  hand  and  gonorrhoic  arthritis  on  the 
other  is  of  common  occurrence  in  every  day 
practice. 


448  GENERALIZED   PAIN 

In  gonorrhoic  arthritis  we  are  confronted  by 
its  monoarticular  characteristics,  i.e.,  that  it  set- 
tles principally  in  the  knee  joint — in  women  also 
in  the  wrist — and  the  contrast  between  the  rela- 
tively low  degree  of  fever  and  the  high  intensity 
of  the  pains. 

However,  there  are  cases  in  which  these  dif- 
ferential symptoms  fail.  I  have  seen,  not  in- 
frequently, polyarticular  forms  of  this  disease 
in  which  several  joints  were  progressively  af- 
fected. Much  information  came  to  me  from 
the  discovery  of  a  fresh  gonorrheal  infection  in 
the  patient,  and  also  from  the  rinding  of  gono- 
cocci  in  the  urethral,  i.e.,  genital  secretions;  and 
again,  it  is  of  importance  to  know  that  gonor- 
rhoic articular  rheumatism  often  develops  only 
after  the  abnormal  secretions  from  the  genital 
organs  have  completely  disappeared.  It  may 
also  be  due  to  latent  gonorrhea  or  to  chronic 
gonorrhoic  prostatitis  which  has  been  overlooked. 
Hidden  gonococci  discovered  by  manual  pres- 
sure furnish  the  evidence.  If  this  prove  a  failure 
we  must  consider  the  peculiarities  of  the  articular 
affection. 

In  the  gonorrhoic  form  we  miss  the  progres- 
sive element  which  is  characteristic  of  acute 
articular  rheumatism,  but  we  find  the  distinctive, 
periarticular,  pasty  edema  extending  far  beyond 
the  articular  limits.  We  also  encounter  endo- 
articular  swellings  and  periarticular  muscular 


JOINTS  449 

atrophy,  intermittent  fever  and  an  early  inclina- 
tion to  ankylosis.  A  trial  puncture  of  the  joint 
shows  a  cloudy,  serous,  cytologic  fluid  consisting 
chiefly  of  polynuclear  leucocytes  (later  on  also 
mononuclear  cells)  and  gonococci.  Further- 
more, the  relatively  long  duration  of  the  disease 
is  a  speaking  factor  not  to  mention  inefficacy  of 
salicylic  treatment,  local  reaction  to  gonococcus 
vaccine  (arthigen).  A  concomitant  disease  of 
the  joints,  foreign  to  acute  articular  rheumatism, 
even  an  isolated  affection,  e.g.,  of  the  maxillary 
arthrosis  or  of  a  sterno-clavicular  articulation 
must  be  taken  as  strong  evidence  of  gonococcal 
arthritis.  An  affection  of  the  endocardium  or 
pericardium,  of  the  pleura  or  peritoneum  does 
not  exclude  gonorrhea  and  in  that  case  we  are 
dealing  with  a  gonococcal  septicopyemia.  Pres- 
ence of  the  gonococcus  in  the  blood  is  positive 
proof. 

Acute  septic  polyarthritis  is  often  erroneously 
disguised  as  acute  articular  rheumatism.  Of 
course,  this  cannot  happen  in  a  classical  case  of 
severe  septicopyemia,  but  is  not  uncommon  in 
cases  of  endocarditis  bacteritica  or  lenta  in  which 
pains  and  swelling  are  of  a  lower  quality  and 
of  short  duration.  Likewise  in  cases  of  a  gen- 
eralized septic  infection  of  a  mitigated  character. 
In  this  condition  the  bacterial  deposit  in  the 
joints  causes  multiple  local  pains  and  swellings. 
Mention  must  be  made  here  of  angina.  In  it 


450  GENERALIZED    PAIN 

as  well  as  in  articular  rheumatism  we  meet  the 
same  difficulty  in  deglutition  and  local  pharyn- 
geal  affections  either  immediately  before  or  with 
the  initial  stages  of  the  attack.  The  matter 
may  be  further  complicated  by  the  fact  that  in 
both  diseases  a  ocncomittant  infection  of  the 
cardiac  valves  and  abnormal  sweating  are  in 
evidence  thus  rendering  an  erroneous  finding 
still  more  plausible. 

If  the  patient  has  been  under  our  observation 
early  enough  we  must  have  noticed  the  lesions 
in  the  pharynx  and  the  painful  swellings  in  the 
lymphatic  glands  of  the  neck,  a  sure  proof  of 
bacterial  infection.  In  the  later  stages  of  septic 
polyarthritis  we  must  fall  back  upon  the  pro- 
gressive nature  of  the  disease,  acute  splenic 
tumor,  marked  hyperhemocytosis  and  positive 
diazo  reaction.  (I  agree  with  R.  Schmidt  that 
the  diazo  reaction  is  a  positive  contraindication 
against  primary  as  well  as  secondary  infectious 
articular  rheumatism  no  matter  of  what  genesis.) 
Furthermore,  I  mention  hemorrhages  or  white 
spots  in  the  retina,  laboratory  examination  of 
the  articular  serum,  be  it  clear  or  cloudy,  like- 
wise of  the  blood  and  relative  failure  of  salicylic 
drugs. 

Akin  to  those  connected  with  septic  poly- 
arthritis are  the  initial  and  later  on  intermittent 
articular  pains  caused  by  endocarditis  lenta  so 
frequently  mistaken  for  articular  rheumatism 


JOINTS  451 

with  concomitant  heart  disease.  The  error  is 
not  pardonable,  for  the  symptoms  are  plain 
enough.  We  have  an  intermittent,  mostly  long 
continued  morbid  condition,  a  leaning  to  in- 
farcts,  a  relatively  hard,  often  painful  tumor  of 
the  spleen,  pronounced  leucocytosis,  embolic 
nephritis,  all  the  symbols  of  a  recent  or  recru- 
descent  endocarditis  and  the  presence  of  the 
streptococcus  viridans  in  the  blood.  We  have, 
moreover,  pus  cells,  gonococci,  influenza  bacillus, 
and  Weichselbaum's  meningococcus,  every  one 
of  them  a  septic  agent.  The  latter  alone  are 
able  to  parade  before  us  under  the  false  face 
of  an  acute  febrile  polyarthritis  without  display- 
ing the  characteristic  symptoms  of  their  own 
isolated,  classic  disease.  To  make  here  a  correct 
diagnosis  of  a  specific,  septic  polyarthritis  is 
only  possible  with  the  aid  of  a  competent  labo- 
ratory examination  of  the  blood  and  the  articular 
fluid,  rarely  through  the  port  of  entry,  i.e.,  the 
postnasal  pharyngeal  cavity. 

A  similar  state  exists  in  paratyphoid  bacillosis 
with  gastro-intestinal  symptoms.  Bacteriologic 
and  serologic  blood  tests  will  make  the  diagnosis 
positive. 

Sepsis  caused  by  the  pneumonia  diplococcus 
requires  mention  here,  too.  The  blood  test  will 
make  us  recognize  it  as  a  true  originator  of 
specific  polyarthritis.  Our  attention  will  be 
quickly  invited  by  the  unusual  adherence  of 


452  GENERALIZED   PAIN 

blood  to  the  fibrin  net  and  leucocytosis  in  the 
absence  of  eosinophile  cells. 

Acute  tuberculous  articular  rheumatism  pre- 
sents pretty  well  the  same  features  as  acute  arti- 
cular rheumatism.  We  have  to  distinguish  here 
between  two  forms.  ( 1 )  The  patient  shows  high 
fever  and  multiple  articular  pains  and  swellings, 
cough,  cyanosis,  dyspnea  and  cerebral  compli- 
cations, and  dies  within  a  week  or  two.  The 
postmortem  reveals  miliary  tuberculosis  impli- 
cating the  joints.  The  diagnosis  in  such  a  case 
is  rather  difficult.  Acute  articular  rheumatism 
is,  practically  speaking,  out  of  the  question; 
but  cerebral  rheumatism  or  miliary  tuberculosis 
involving  the  meninges  might  be  considered,  and 
above  all  septic  infection.  The  differential  diag- 
nosis is  confined  to  miliary  tuberculosis  and 
septic,  infectious-chorioidal  tubercles,  dyspnea 
and  cyanosis  with  negative  pulmonary  findings, 
rather  soft  tumor  of  the  spleen,  positive  diazo 
reaction,  leucopenia  with  polynucleosis  and  pro- 
gressive lymphopenia  and  monopenia  in  miliary 
tuberculosis,  hemorrhagie  retinitis,  cutaneous 
hemorrhages,  pain  in  the  bones,  leucocytosis 
(only  in  severe  cases  of  leucopenia),  absence 
of  lymphocytosis  (nearly  always  with  lympho- 
penia in  sepsis).  So  far  as  special  localization 
in  the  joints  is  concerned  the  bacteriological  find- 
ings of  the  articular  fluid  and  of  the  blood  should 
prove  useful.  Of  the  cytologic  conditions  of 


JOINTS  453 

the  articular  contents  we  have  no  definite  knowl- 
edge. It  is  not  unlikely  that  in  these  cases  mul- 
tiple articular  swellings  and  an  accumulation  of 
fluid  in  the  abdominal  cavity  together  with  k)cal 
tenderness  are  found. 

(2)  The  second  form  approaches  more  closely 
the  clinical  picture  of  articular  rheumatism,  but 
similar  conditions  as  under  (1)  prevail:  pains  in 
the  joints,  likewise  enlargements,  high  tempera- 
ture, generally  constant  above  39°  centigrade. 
The  differentiating  points,  however,  are:  we 
observe,  as  a  rule,  no  local  reddening  of  the  skin, 
no  characteristic,  sour  -  smelling  perspiration ; 
witness  the  progress  of  the  disease  by  bounding 
into  new  joints,  the  absence  of  complicating 
cardiac  affections,  the  failure  of  salicylic  treat- 
ment except  that  it  mitigates  the  pain  and  some- 
what reduces  the  swellings,  lymphocytosis  of  the 
articular  fluid  and  above  all  the  local  reaction 
of  tuberculin.  Pulmonary  tuberculosis  and 
other  tuberculous  phenomena  may  be  concomit- 
ant symptoms  and  materially  assist  in  the  diag- 
nosis which  will  find  another  adjuvant  in  the 
general  course  of  the  disease. 

Multiple  painful  articular  swellings  and  some- 
times local  reddening  of  the  skin  are  not  un- 
usual in  resorption  of  tuberculous  serous  exu- 
dates,  especially  in  the  pleura. 

Tuberculosis  may  also  be  the  generator  of 
simple  toxic  multiple  arthralgia.  The  same 


454  GENERALIZED   PAIN 

applies  to  syphiUs.  On  the  ground  that  acute 
articular  rheumatism  is  able  to  provoke  multiple 
pains  in  the  joints  strongly  resembling  those 
due  to  such  arthralgias,  a  confusion  in  the  diag- 
nosis is  likely  to  arise.  But  salicylic  drugs 
promptly  clear  up  the  situation. 

This  applies  in  the  same  measure  to  secondary 
syphilis  when  the  patient  suffers  from  pains  in 
the  joints  that  are  accompanied  by  fever  and 
general  indisposition,  but  not  local  changes.  It 
is  different,  however,  when  local  reddening  of 
the  skin  is  noticeable.  The  salicylic  test  is  here 
not  adequate.  We  must  watch  closely  the  pro- 
gressive nature  of  the  pains,  look  out  for  tumors 
in  the  spleen  and  make  sure  of  the  character  of 
the  primary  affection;  search  for  the  presence 
of  spirochetes  and  the  Wassermann  reaction 
become  a  necessity. 

A  differential  diagnosis  between  syphilitic 
arthritis  and  gonorrhoic  articular  affections  is 
urged  upon  us  when  a  chancre  with  purulent 
discharge  is  discovered  in  the  urethra.  The 
distinguishing  features  are  easily  recognized:  in 
syphilis  the  articular  swellings  are  less  painful, 
or  even  painless  altogether,  whilst  in  articular 
rheumatism  we  have  multiple  localization,  evi- 
dence of  bacteriologic  and  serologic  tests,  and 
extreme  local  painfulness,  to  which  in  gonor- 
rhoic arthritis  is  also  added  affection  of  the 
periarticular  tissue. 


JOINTS  455 

Late  syphilis  sets  in  years  after  the  initial 
attack  has  been  overcome  with  or  without  fever 
and  even  without  swelling  in  any  of  the  joints. 
In  such  cases  where  doubt  exists  it  is  advisable 
to  resort  to  antirheumatic  therapeutic  measures. 
With  negative  results  we  know  that  the  disease 
is  not  rheumatism  but  of  a  tuberculous  or  syphi- 
litic nature.  The  Wassermann  reaction  and 
antiluetic  remedies  will  clear  up  the  situation 
still  further.  Remember  also  that  tuberculosis 
is  indicated  by  the  presence  of  a  pronounced 
splenic  tumor. 

There  are  other  cases  of  indubitable  aortic 
insufficiency  with  slight  dilatation  of  the  heart 
in  which  the  anamnesis  lays  bare  a  pristine 
attack  of  syphilis  or  acute  articular  rheumatism. 
And  again,  I  have  seen  individuals  with  unde- 
niable gonorrhea  who  were  suffering  from  pains 
and  swellings  in  several  joints  and  yet  they 
proved  to  be  cases  of  genuine  syphilitic  articular 
rheumatism. 

Multiple  enlargements  of  the  lymphatic  glands 
are  of  importance  in  the  diagnosis  not  only  of 
syphilitic  conditions  but  particularly  so  of  acute 
rheumatism  in  the  joints.  As  a  rule  they  are 
strung  together  in  chains  or  in  groups  around 
the  affected  joint  and  are  sensitive  on  pressure. 
Both  these  qualities  are  helpful  in  differentiating 
between  syphilis  and  acute  articular  rheumatism. 


456  GENERALIZED   PAIN 

In  the  former  the  swellings  are  universal  and 
indolent,  in  the  latter  sensitive  and  regional. 

In  the  Still-Chaufford  disease  of  which  we 
have  all  seen  so  much  during  recent  years,  we 
find  multiple  swellings  of  the  lymphatic  glands 
with  multiple  affections  of  the  joints,  (also 
accompanied  by  swelling  and  articular  pain)  in 
every  form  of  the  ailment  from  the  subacute  to 
the  subchronic  stage;  sometimes  also  periodic 
or  else  continuous  subfebrile  temperature.  The 
joints  are  painful  and  disfigured — more  in  the 
sense  of  multiple  chronic  articular  rheumatism 
without  ankylosis — ,  the  glands  are  fused  and 
tumefied,  those  in  the  armpits  may  lie  so  deep 
that  they  escape  attention  unless  the  patient  is 
examined  in  an  upright  posture  (the  histologic 
examination  of  excised  glands  does  not  show 
a  distinctive  pathological  tissue  form  but  only 
the  picture  of  a  simple  fibroadenitis).  We 
further  find  a  moderately  hard  splenic  tumor, 
vasomotoric  disturbances  (cold  hands),  exoph- 
thalmos,  tachycardia  and  slightly  raised  temper- 
ature. In  some  cases  we  may  also  observe  a 
slight  tuberculous  apex  affection,  or  indurated 
mediastinitis  or  a  questionable  pericardiac  con- 
cretion with  the  heart.  In  my  experience  I 
have  found  on  several  occasions  that  the  general 
as  well  as  the  local  reactions  in  the  joints  and 
glands  to  bovine  tuberculin  were  very  much 
stronger  than  to  the  human  product,  i.e.,  the 


JOINTS  457 

curative  qualities  of  the  former  were  more  strik- 
ing and  satisfactory,  for  which  reason  I  took, 
at  any  rate,  several  cases  of  this  disease  as  a 
specific  form  of  bovine  tuberculous  articular 
rheumatism. 

In  acute  leucemia  enlargements  of  the  joints 
and  glands  are  by  no  means  a  rarity. 

There  is  another  form  of  typical  chronic, 
articular  rheumatism,  though  not  very  common, 
with  strong  pains,  exudation  in  the  joints  and 
ulnar  position  of  both  hands  which  we  may 
witness  in  young  women.  We  shall  find  chronic 
indolent  lymphatic  swellings  in  the  armpit  as 
well  as  in  the  forearm,  not  a  trace  of  tuber- 
culous affection  in  the  whole  system,  but  evident 
endocarditis  of  some  standing  and  mitral  sten- 
osis and  insufficiency.  The  genesis  seems  to  be 
not  subject  to  doubt. 

Among  the  infectious  articular  rheumatoids 
or  pseudo-rheumatisms  I  name  here  first  scarla- 
tinous polyarthritis,  a  polyarthritis  which  ap- 
pears in  the  second  or  towards  the  end  of  the 
fourth  week  of  the  disease.  It  is  a  serous,  some- 
times a  purulent  affection  of  various  joints, 
finger,  hand,  foot  or  knee,  often  accompanied 
by  pericarditis,  more  rarely  by  endocarditis. 
When  it  follows  on  top  of  a  purulent  arthritis 
it  assumes  a  septic  pyemic  character.  It  differs 
from  the  common  form  of  articular  rheumatism 
insofar  that  it  does  not,  like  the  latter  spread 


458  GENERALIZED    PAIN 

by  leaps,  as  it  were,  from  one  joint  to  others, 
but  persists  in  the  affected  parts  to  disappear 
again  after  three  or  four  days.  The  joints  may 
be  similarly  affected  in  smallpox,  chickenpox, 
erysipelas,  possibly  with  endo-myocarditis,  and 
also  in  influenza,  but  with  more  frequency  in 
or  after  pneumonia.  In  other  localized  diplo- 
coccus  infections,  e.g.,  ulcerating  teeth  or  otitis, 
generally  only  one  joint,  preferably  the  shoulder, 
is  involved  unless  streptococcic  infection  super- 
sedes. It  follows  also  in  the  wake  of  dysentery 
(with  stubborn  persistence  in  a  single  joint),  the 
same  as  in  ulcerous  colitis  complicated  with 
endocarditis.  The  attack  survives  the  original 
sickness  for  a  considerable  span  of  time  and 
sometimes  only  sets  in  as  an  aftereffect  when 
the  characteristic  intestinal  manifestations  have 
already  gone  away. 

Under  the  last  named  conditions  pseudo-rheu- 
matism in  colitis  may  set  in  all  of  a  sudden  after 
a  chill,  with  high  fever,  intensive  pains,  immo- 
bility and  swelling  of  the  joint  with  reddening 
of  the  skin,  to  last  for  several  months.  Con- 
siderable disfiguration  and  periarticular  muscu- 
lar atrophy  are  seen,  and  yet  complete  recovery 
takes  place,  sometimes  after  cecostomy. 

In  sporadic  instances  of  multiple  articular 
pain  and  swelling  after  dysentery  we  may  have 
to  deal  with  a  case  of  septic  polyarthritis  instead 
of  the  aforementioned  toxic  pseudorheumatism 


JOINTS  459 

when  the  blood  becomes  irritated  by  the  invasion 
of  bacteria  (e.g.,  streptococci)  into  the  blood 
from  an  intestinal  ulcer.  The  blood  test  will 
confirm  this.  Even  in  ordinary  diarrhea  enteric 
polyarthritis  may  be  observed.  Although  here 
the  local  reddening  of  the  skin,  heat,  sweating 
and  cardiac  complications  are  not  in  evidence 
and  salicylic  remedies  prove  ineffective,  we  often 
find  conjunctivitis  and  urethritis  in  company 
with  this  disease. 

Mono-  and  polyarthritic  conditions  are  not  so 
common  in  epidemic  cerebrospinal  meningitis 
(see  "Sacralgia"),  or  in  epidemic  encephalitis, 
in  malaria,,  (especially  tropical  malaria,  and  the 
chronic  type  with  intermittent  articular  swell- 
ings) or  in  diphtheria,  but  are  very  rare  in 
measles,  German  measles,  whooping  cough,  vari- 
cella and  spotted  typhus,  although  in  all  these 
diseases  they  are  more  in  the  nature  of  arthral- 
gias  of  an  infectious  toxic  origin. 

A  similar  state  exists  in  the  initial  stages  of 
tetanus.  In  leprosy  very  severe  pains  and  swell- 
ings in  the  joints  with  fever  prevail  analogous 
to  syphilitic  polyarthritis  and  periarthritLs. 
These  arthralgias  either  accompany  the  incipient 
stages  of  the  infection  or  develop  gradually  dur- 
ing its  course.  If  the  former  is  the  case  an 
erroneous  diagnosis  of  acute  articular  rheuma- 
tism or  a  sepsis  is  not  excluded,  for  instance,  in 
smallpox  in  which  articular  pains  are  often 


460  GENERALIZED   PAIN 

predominant.  Here  we  must  be  guided  by  the 
other  early  signs,  namely  pains  in  the  sacrum, 
prodromal  exanthema,  the  eruption  of  papules 
on  the  mucous  membranes  of  the  eyes,  mouth 
and  throat,  negative  bacteriologic  findings,  cyto- 
logic  condition  of  the  blood  (in  sepsis  leucocyto- 
sis,  leucopenia  with  neutrophilia  or  lymphopenia, 
in  variola  leucocytosis  and  monocytosis).  In 
influenza  arthralgias  are  very  common. 

Serum  injections  frequently  cause  articular 
swellings  and  local  pain,  also  in  lymphatic 
glands,  with  high  temperature  and  marked  dis- 
turbances in  the  general  condition  of  the  body; 
even  herpes  and  albuminuria  may  be  concomit- 
ant factors.  After  two  or  three  days  these 
manifestations  disappear  again.  The  absorption 
of  any  hydropic  fluid,  e.g.,  of  a  serous,  tubercu- 
lous pleural  exudate,  in  the  system  has  the  same 
effect,  an  anaphylactic  manifestation,  no  doubt, 
due  to  the  influence  of  endogenous  albumin. 

In  paroxysmal  hemoglobinuria  the  pains  in 
the  joints  are  not  accompanied  by  swellings  or 
other  articular  changes  and  disappear  with  the 
attack. 

Very  tenaceous  pains  go  with  recurrent  fever, 
especially  in  one  or  more  of  the  larger  joints, 
but  without  swelling.  Sometimes  they  are  of 
such  a  vicious  character  that  they  are  easily 
taken  for  articular  rheumatism,  but  the  tempera- 
ture, the  enlargement  of  the  spleen  and  the 


JOINTS  461 

presence  of  spirochetes  in  the  blood  will  soon 
bare  the  error. 

In  dengue  fever  pains  and  enlargements  in 
the  joints,  reddening  of  the  skin,  fever,  affecting 
one  joint  after  another,  are  typical  symptoms 
of  the  disease.  A  false  diagnosis  of  acute  arti- 
cular rheumatism  or  of  acute  influenza  is  not 
among  the  impossibilities.  The  geographical 
locality  in  which  the  disease  occurs  must  be 
considered.  Generally  speaking  a  close  obser- 
vation of  the  course  taken  by  the  malady  will 
secure  a  positive  diagnosis,  especially  if  one 
bears  in  mind  that  besides  the  symptoms  already 
enumerated  there  exist  also  stiffness  in  the  knee 
and  other  joints,  likewise  in  the  vertebrae,  loss 
of  appetite  and  a  thickly  coated  tongue.  The 
fever  is  on  the  wane  within  three  to  seven  days, 
perspiration  is  copious,  but  a  few  days  later 
high  temperature  returns,  the  articular  pains 
come  back  and  with  them  exanthema  appears 
in  the  face,  on  the  hands  and  the  forearms,  simi- 
lar to  purpura  or  measles.  The  skin  peels  off 
soon  afterwards  and  a  slow  recovery  ensues. 

In  Malta  fever  the  patient  suffers  from  mul- 
tiple pain  chiefly  in  the  larger  joints  which  set 
in  about  two  weeks  after  the  beginning  of  this 
pseudotyphoid  disease.  The  principal  symptoms 
are  gradual  rise  of  temperature,  chills,  continu- 
ous remittent  or  intermittent  fever,  frequent 
heavy  sweating,  thickly  coated  tongue,  nausea, 


462  GENERALIZED   PAIN 

vomiting,  constipation,  meteorism  and  acute 
splenic  tumor.  The  pains  are  of  a  rheumatic 
nature  affecting  one  or  more  of  the  joints.  We 
notice  swellings  and  local  reddening  of  the  skin, 
serous  extravasations  in  the  shoulder,  hip  or 
knee  joints  for  a  month  or  so.  When  the  acute 
articular  affections  make  their  appearance  at 
the  very  beginning  of  the  disease,  as  seems  to 
be  the  case  sometimes,  the  differential  diagnosis 
from  acute  articular  rheumatism  is  not  so  easy. 
The  agglutination  test  for  micrococcus  meliten- 
sis  and  certain  clinical  signs  such  as  painful 
testicles  should,  however,  positively  distinguish 
this  disease  from  articular  rheumatism  as  well 
as  from  septic  polyarthritis.  This  refers  with 
like  force  to  those  cases  in  which  a  metastatic 
purulent  arthritis  results  from  Malta  fever. 

More  difficult  is  the  differentiation  from  ab- 
dominal typhoid,  especially  arthrotyphoid.  This, 
of  course,  refers  only  to  those  cases  in  which 
pains  in  several  joints  with  swelling  and  redden- 
ing accompany  the  symptoms  of  typhoid.  The 
resemblance  to  acute  articular  rheumatism  may 
here  easily  lead  to  some  mistake.  But  when 
we  observe  that  the  affection  does  not  bound, 
as  it  were,  from  one  joint  to  various  other  joints, 
that  the  characteristic  perspiration  is  wanting 
the  diagnosis  of  abdominal  typhoid  should  be 
made  positive,  especially  in  the  presence  of  a 
tumor  in  the  spleen,  of  bronchitis,  of  a  diazo 


JOINTS  463 

reaction  (when  urobilinogenuria  is  absent),  of 
leuco-  and  neutropenia  with  lymphocytosis  and 
eosinophilia,  not  to  forget  the  bacteriological 
blood  test  and  the  Gruber-Widal  reaction.  It 
is  worth  while  also  to  remember  that  in  abdom- 
inal typhoid  fever  secondary,  mostly  purulent 
articular  affections  make  at  times  their  appear- 
ance. They  are  of  great  importance  for  a  cor- 
rect etiologic  diagnosis.  Especially  in  children 
localized  pains  in  the  cervical  spine  with  wry- 
neck have  been  observed  which  makes  it  advisable 
to  think  of  a  possible  typhoid  infection  when 
dealing  with  a  case  of  feverish  torticollis. 

That  antityphoid  serum  may  cause  articular 
pains  has  already  been  mentioned.  But  I  will 
add  here  that  acute  polyarthritis  with  light  fever 
and  a  septic  aspect  may  originate  in  a  typhoid 
carrier  by  way  of  auto-intoxication  thus  pro- 
ducing a  typhoid  badllary  septicemia. 

In  paratyphoid  articular  pains  and  swellings 
of  an  infectious  toxic  nature  may  also  be  ob- 
. served.  In  fact  the  paratyphoid  bacillus  may  in 
some  instances  be  the  causative  element  of  an 
acute,  purulent  arthritis.  In  a  like  manner 
multiple  affections  of  the  joints  may  be  con- 
ditioned by  a  coli  infection,  i.e.,  in  severe  cases 
of  enterocolitis.  Or  in  the  absence  of  a  coli 
infection  the  articular  pains  can  just  as  well 
be  merely  the  expression  of  a  coli  bacillosis. 

I  have  already  mentioned   in  another  place 


464  GENERALIZED   PAIN 

that  in  trichinosis  a  paratyphoid  state  combined 
with  articular  pains  is  not  an  unusual  occur- 
rence. 

While  speaking  of  the  differential  diagnosis 
between  arihrotyphoid  and  articular  rheumatism 
I  wish  to  call  attention  to  another  point  of  im- 
portance. It  is  this:  abdominal  typhoid,  like 
many  other  infectious  diesases,  is  apt  to  revive 
a  dormant  articular  rheumatism  with  all  its  pris- 
tine pains  and  changes  in  the  very  joints  which 
were  affected  by  the  primary  attack.  In  other 
words  every  acute  infectious  disease  that  is  cap- 
able of  producing  morbid  conditions  in  the  joints 
may  be  the  connecting  link  between  the  infection 
and  genuine  acute  articular  rheumatism.  Ty- 
phoid and  gonorrhoic  polyarthritis  are  by  no 
means  an  impossible  combination. 

Glanders  (malleus)  in  the  acute  form  bears 
a  stronger  resemblance  to  septic  pyemia  than 
to  articular  rheumatism.  In  the  primary  stages 
of  this  disease  we  observe  a  painful  infiltration 
of  the  skin  which  rapidly  develops  boils  typical 
of  farcy;  the  surrounding  lymphatic  glands  and 
vessels  are  inflamed;  the  nose  is  infected  with 
a  specific  form  of  rhinitis  and  sores  form  along 
its  margin  and  in  the  mucous  membrane.  But 
when  these  typical  symptoms  are  not  present 
we  only  gain  the  impression  of  a  general  severe 
septic  pyemia,  the  more  so  as  towards  the  end 
of  the  first  week  the  eruption  in  the  skin  looks 


JOINTS  465 

very  much  like  a  multiple,  at  first  papular,  then 
pustular  exanthema.  Most  conspicuous  are  the 
multiple  affections  of  the  joints  and  muscles 
by  purulent  exudates,  the  formation  of  pustules 
on  the  skin  and  the  mucous  membranes,  of  ab- 
scesses in  the  muscles  and  pus  under  the  skin, 
genuine  guiding  symptoms  for  a  correct  diag- 
nosis, which  may  be  further  assisted  by  the 
anamnesis  (contact  with  animals),  bacteriologic 
examination  of  the  pus,  etc.,  for  the  presence 
of  the  malleus  bacillus. 

The  diagnosis,  of  course,  will  be  more  difficult 
when  an  acute  attack  after  several  days  of  con- 
tinuous fever  with  very  severe  pains  suddenly 
develops  swelling  of  one  or  more  joints,  thus 
simulating  a  multiple  septic  arthritis.  But  we 
shall  find  safety  from  error  if  we  consider  the 
following  points.  Malleus  shows  a  distinct, 
diffuse  reddening  of  the  skin  of  a  deep  hue  as 
in  erysipelas,  almost  brownish  red,  a  simulta- 
neous infiltration  of  the  skin  which  subsequently 
reaches  into  the  muscles,  and  cutaneous  pustules 
typically  characteristic  of  malleus. 

Farcy  sometimes  travels  under  the  guise  of 
subacute  disease.  It  is  then  somewhat  difficult 
to  arrive  at  a  proper  conclusion.  The  main 
points  to  keep  in  view  are  always:  examination 
of  the  blood,  livid  red  coloration  of  the  skin  over 
the  affected  joint,  edema tous  infiltration  of  the 
surrounding  parts,  mild  febrile  conditions  and 


466  GENERALIZED   PAIN 

general  indisposition.  I  may  add  that  chronic 
malleus  may  persist  for  several  months. 

Sporotrichosis  is  likewise  connected  with  arti- 
cular pains  and  sometimes  with  hydrarthros.  The 
presence  of  subacute,  gummatous  nodes,  fistulas, 
resemblance  to  tertiary  syphilis,  and  Beurmann's 
sporotrichon  should  be  sufficient  evidence  for 
a  correct  diagnosis. 

Periarteritis  nodosa  presents  sometimes  a  sep- 
tic aspect  with  sporadic  pains  and  swellings  in 
several  joints.  The  diagnosis  is  fully  discussed 
in  "Abdominal  Pain"  and  in  the  section  on 
"Muscular  Pain,"  and  will  again  be  referred 
to  under  "Typhoid  Diseases." 

Acute  leucemia  is  apt  to  be  ushered  in  by 
multiple  articular  pains  and  changes  thus  lead- 
ing to  the  false  impression  of  articular  rheuma- 
tism or  septic  polyarthritis.  To  differentiate 
look  for  signs  of  scurvy  in  the  mouth,  more 
generalized  glandular  swellings,  harder  consis- 
tence of  the  splenic  tumor,  progressive  pallor 
and  tendency  towards  hemorrhages,  and  do  not 
neglect  the  blood  test.  Our  present  state  of 
knowledge  does  not  in  any  way  clear  up  the 
relation  of  myeloid  leucemia  to  streptococcic 
sepsis,  for  we  must  remember  that  in  sepsis  both 
myelocytes  and  lymphocytes  may  be  found  in 
the  blood. 

In  eri/sipeloid  pain  and  bulging  are  observable 
in  the  middle  joints  of  the  fingers.  The  color 


JOINTS  467 

of  the  skin  is  of  a  bluish,  violet  tint  and  reaches 
out  in  tongue-shaped  extensions  with  pale  spaces 
between  them. 

Rheumatic  peliosis  with  multiple  articular 
pains  and  prominences  distinguishes  itself  from 
articular  rheumatism  by  periarticular  hemor- 
rhages especially  on  the  minor  surfaces  of  the 
extremities.  Still  it  is  wise  to  bear  in  mind 
that  arthralgias  are  not  an  uncommon  occurrence 
in  the  beginning  of  purpura  hemorrhagica  and 
likewise  in  scurvy.  In  the  latter  disease  par- 
ticularly severe  pains  are  caused  by  hemorrhages 
into  the  joints  which  become  enormously  en- 
larged almost  reaching  the  stage  of  an  anky- 
losis. 

In  hemophilia  and  hemophilic  hemarthrosis 
the  hemorrhages  into  the  joints  cause  exquisite 
pain  therein.  If  there  is  also  high  temperature 
and  we  are  not  aware  of  the  fact  that  the  patient 
is  a  bleeder,  we  may  easily  be  led  astray  and 
make  a  diagnosis  of  articular  rheumatism  or 
even  of  acute  monarthritis.  A  careful  anam- 
nesis is  of  paramount  necessity  in  all  such  cases. 
Additional  adjuvants  are  found  in  the  presence 
of  other  hemorrhages,  diminished  coagulation  of 
the  blood  during  the  intervals  which  gradually 
reaches  the  normal  stage  with  the  ensuing  hemor- 
rhage (extravascular  coagulation),  and  concom- 
itant lymphocytosis  with  a  normal  count  of  the 
blood  platelets.  Hemarthros  ends  either  in  a 


468  GENERALIZED   PAIN 

slow  recovery  or  degenerates  into  a  chronic  con- 
dition with  resulting  ankylosis. 

I  will  now  speak  of  those  articular  diseases 
which  are  not  necessarily  of  a  metastatic  origin. 

Foremost  among  these  is  gout,  a  constitutional 
disease  which  is  more  frequently  the  causative 
factor  of  monarthritis  than  of  polyarthritis.  If 
it  affects  only  one  particular  joint,  for  instance, 
that  of  the  big  toe  (podagra)  or  at  any  rate 
only  the  distal  joints  of  the  lower  extremities 
we  have  a  very  fair  proof  of  its  monoarticular 
nature.  But  gout  may  also  attack  the  upper 
extremities  (chiragra,  omagra)  or  some  other 
joint,  or  even  quite  a  number  of  joints.  In  any 
case  it  is  always  characterized  by  the  fact  that 
the  pains  generally  set  in  after  midnight,  or  if 
they  do  come  on  in  the  daytime  they  grow 
worse  during  the  night.  The  patient  is  slightly 
feverish,  the  skin  shows  a  velvety  blush  which 
tapers  into  the  normal  of  the  surrounding  parts, 
is  shiny,  tense  and  hot,  with  tactile  hyperesthesia 
and  hyperalgesia,  is  marked  with  lymphangitic 
stria?,  and  the  cutaneous  veins  are  puffed  up. 
The  attack  generally  lasts  from  three  to  four 
days  or  a  week.  This  differentiates  it  from 
articular  rheumatism. 

I  have  already  said  on  a  previous  occasion 
that  gout  is  one  of  the  hereditary  diseases,  also 
that  it  is  characterized  by  the  peculiar  behavior 
of  the  uric  acid  in  the  blood  (hyperuricemia) 


JOINTS  469 

and  that  an  attack  may  be.  provoked  by  the 
consumption  of  nucleins.  But  I  will  add  here 
that  a  multiple  acute  articular  affection  which 
makes  its  appearance  for  the  first  time  after 
the  age  of  50  should  arouse  the  suspicion  of  a 
possible  gouty  involvement.  But  it  does  not 
always  prove  true.  On  the  other  hand  persons 
who  have  suffered  in  bygone  days  from  articular 
rheumatism  are  not  immune  from  an  attack  of 
genuine  gout  in  later  years  in  the  very  joint  or 
joints  that  were  involved  by  the  previous  attack. 
I  will  refer  to  the  differential  diagnosis  between 
gout  and  other  articular  affections  later  on  when 
speaking  of  the  rudimentary  development  of 
this  ailment. 

Although  the  chrome  form  of  multiple  arti- 
cular rheumatism  shows  a  strong  resemblance 
in  its  incipient  stages  to  the  acute  attack,  yet 
there  are  certain  definite  signs  by  which  the  two 
can  be  separated.  First  of  all  there  is  the  course 
of  the  disease  itself,  then  there  is  the  fact  that 
in  chronic  rheumatism  it  is  particularly  the 
joints,  especially  the  small  ones  of  the  upper 
extremities  that  are  involved,  there  is  no  recov- 
ery in  the  joints  once  affected  when  the  disease 
leaps  into  others,  characteristic  sweating  is  ab- 
sent, but  there  is  a  prompt  response  to  salicylic 
treatment.  Consider  also  moderate  rise  of  tem- 
perature, the  stubbornness  of  the  disease  and 
the  rare  occurrence  of  complicating  heart  dis- 


470  GENERALIZED   PAIN 

eases.  I  am  inclined  to  believe  that  the  origi- 
nating force  is  to  be  found  in  some  primary 
affections  of  the  oral  cavities,  more  likely  than 
not  in  the  tonsils. 

There  are  other  acute  diseases  which  do  not 
originate  from  the  joints  themselves  but  from 
adjacent  parts  such  as  the  epiphyses  of  the 
bones,  and  in  consequence  are  mistaken  for 
acute  rheumatic  or  septic  arthritis.  In  such 
cases  we  should  always  think  of  the  possibility 
of  an  existing  osteomyelitis  or  syphilitic  ostitis. 
If  only  one  joint  is  involved  a  monarthritis  may 
be  simulated,  but  generally  several  joints  are 
affected.  In  purulent  osteomyelitis  the  joints 
are  swollen  and  their  integument  is  reddened, 
the  patient  complains  of  local  pain  (more  acute 
in  motoric  action),  chills  and  fever.  If  upon 
careful  scrutiny  we  find  that  pain  and  tender- 
ness are  more  acute  in  the  adjacent  osseous 
parts  than  in  the  joint  itself  and  that  the  swell- 
ing extends  beyond  the  capsule,  the  diagnosis 
of  osteomyelitis  is  correct.  The  X-ray  can 
easily  confirm  such  a  finding,  doubly  assured 
by  the  development  of  an  edema  and  the  livid 
coloring  of  the  skin  over  the  affected  part,  the 
presence  of  lymphangitic  stria3  and  the  cordlike 
appearance  of  the  superficial  veins.  I  may  add 
that  in  osteomyelitis  fever  and  pain  precede  the 
swelling,  while  in  arthritis  they  come  at  one 
and  the  same  time.  This  is  important  insofar 


JOINTS  471 

as  a  purulent  monarthritis  of  metastatic  origin 
may  easily  obscure  the  primary  infection. 

Luetic  ostitis  is  mentioned  here  because  in  it 
gummatous  growths  are  formed  in  the  bone 
under  the  peristeum  nearest  to  the  joint  which 
may  be  taken  for  mon-  or  polyarthritic  condi- 
tions. Analogously  we  find  in  arthritis  gummosa 
intermittent  or  periodic  fever  as  a  concomitant 
of  the  gummatous  affections  of  internal  organs. 
The  anamnesis,  the  typical  symptoms  of  syphi- 
lis, the  Wassermann  reaction,  specific  treatment 
and  the  Roentgen-ray  should  not  leave  the  diag- 
nosis in  doubt. 

Jacksch's  disease  is  another  carrier  of  articular 
pains.  The  patient  is  subject  to  irregular  at- 
tacks of  fever  and  to  pains  in  the  joints  or  in 
the  extremities.  A  careful  study  of  the  disease 
shows  that  the  pain  is  really  located  in  the  bones 
and  not  in  the  joints,  for  the  Roentgen-ray 
distinctly  reveals  a  thickening  of  the  periosteum. 
Salicylic  treatment  is  ineffective  which  at  once 
speaks  against  rheumatism.  But  if  endocarditic 
complications  accede,  which  is  often  the  case, 
the  diagnosis  may  meet  with  obstacles.  Much 
help  is  derived  from  the  clinical  examination  of 
the  blood  for  an  increased  number  of  polynu- 
clear  or  eosinophile  leucocytes  and,  perhaps,  also 
myelocytes.  I  cannot  speak  from  personal  ex- 
perience as  I  have  never  seen  a  case  of  this 
ailment.  I  must  admit  this  also  of  tetanus,  for 


472  GENERALIZED   PAIN 

which  it  is  claimed  that  during  the  so-called 
latent  period  dragging  pains  in  the  extremities 
are  in  evidence  in  addition  to  swelling  and  red- 
dening of  one  or  more  joints,  even  eruptions 
resembling  purpura  as  an  expression  of  vaso- 
motortic  disturbances.  In  Basedovo's  disease  and 
arthrogryposis  similar  observations  have  been 
made.  In  bronchiectasy  and  pulmonary  emphy- 
sema, both  closely  related  to  osteoarthropathy, 
the  articular  changes  are  subject  to  many  fluc- 
tuations; they  come  and  go  to  reappear  again 
during  many  weary  months. 

The  acute,  painful,  articular  swellings  at  the 
beginning  of  a  multiple  insular  sclerosis  find 
their  explanation  in  the  presence  of  other  initial 
symptoms  of  this  disease,  such  as  painful  pares- 
thesias  of  the  extremities,  intention-tremor,  nys- 
tagmus, missing  abdominal  reflex  by  increased 
tendon  reflex,  visual  disorders,  headaches,  ver- 
tigo, disturbances  of  speech  and  bladder. 

In  acute  polyneuritis  acute  articular  swellings 
coupled  with  sensibility  and  motility  disturb- 
ances in  other  parts  of  the  body  are  bound  to 
interfere  with  proper  diagnosing.  I  say  pur- 
posely "in  other  parts  of  the  body,"  because  if 
these  symptoms  manifest  themselves  in  the  im- 
mediate surroundings  of  the  swollen  joints  the 
priginating'  cause  may  be  found  in  a  secondary 
periarticular  neuritis  due  to  the  primary  affec- 
tion of  the  joint.  The  differential  diagnosis, 


JOINTS  473 

i.e.,  whether  we  have  before  us  a  case  of  a  pri- 
mary neuritis  with  a  secondary  articular  swell- 
ing, or  vice  versa,  may  be  a  difficult  problem 
to  solve,  because  motoric  impairment  is  evident 
in  both  cases.  It,  that  is  the  diagnosis,  can  only 
be  based  upon  the  fact  that  "neuritic  changes" 
may  exist  in  places  where  no  articular  swelling 
can  be  proved,  and  upon  the  X-ray.  (See 
"Shoulder  Pains.") 

An  attack  of  acute  polyneuritis  may  be  mis- 
taken for  that  of  acute  articular  rheumatism  in 
the  absence  of  swellings  dependent  on  polyneu- 
ritis. But  this  error  can  be  quickly  mended  by 
a  careful  search  for  tenderness  ig  the  muscles 
and  nerves,  enlargements  in  the  latter,  sensi- 
bility and  motoric  disorders  and  anomalous 
tendon  reflexes,  all  of  which  defects  are  claimed 
by  polyneuritis. 

Ischias  may  be  taken  for  gonitis.  In  both 
the  patient  complains  only  of  pains  in  the  knee- 
joint  or  close  to  it.  Observations  of  tendon 
and  skin  reflexes,  pressure  points  and  the  appur- 
tenant signs  of  ischias  should  prevent  the  error. 

During  the  incipient  stages  of  acute  polio- 
myelitis  in  children  we  may  observe  similar  con- 
ditions as  in  acute  articular  rheumatism,  i.e., 
the  patient  lies  motionless  in  bed  and  complains 
of  pains  in  the  arms  and  legs  and  all  the  mem- 
bers of  the  body  which  are  aggravated  by  any 
attempt  to  move.  Only  the  most  exacting  ob- 


474  GENERALIZED   PAIN 

servation  of  the  tendon  reflexes,  lumbar  punc- 
ture ( ?)  and  the  epidemiologic  moment  will 
bring  light  in  the  situation. 

Besides  the  diseases  referred  to  in  the  fore- 
going pages  there  are  certain  other  rudimentary 
forms  of  articular  rheumatism  to  which  we  must 
advert  in  this  place.  In  mitigated  articular 
rheumatism  the  pains  and  anatomical  changes 
are  of  a  less  virulent,  milder  type,  the  disease 
develops  only  in  one  joint  with  less  pain  and 
less  noticeable  swelling. 

The  diagnosis  will  find  much  assistance  in 
the  fact  that  the  attacks  come  by  leaps  and 
bounds  now  in  this,  then  suddenly  in  another 
joint,  there  is  tendency  towards  perspiring, 
hardly  any  fever,  if  at  all,  localization  in  small 
as  well  as  in  larger  joints  and  a  prompt  reaction 
to  salicylic  drugs.  The  anamnesis  is  most  useful 
insofar  as  it  generally  reveals  the  fact  of  a  pre- 
vious attack  of  typical  fullblown  articular  rheu- 
matism. 

These  low  grade  polyarthritic  forms  are  often 
symptomatic  of  some  mild  septic  infection.  If 
a  catarrhal  angina  preceded  the  attack,  the  diag- 
nosis may  be  somewhat  troublesome,  but  the 
symptoms  described  above  should  suffice  to  re- 
move the  doubtful  element. 

During  the  menstrual  period  high  tempera- 
ture, pain  and  swelling  in  the  joints,  general 
indisposition  are  common  affairs.  In  some  in- 


JOINTS  475 

stances  they  might  arouse  the  suspicion  of  some 
latent  tuberculous  condition,  and  it  is  advisable 
to  make  proper  inquiries  in  this  direction.  In 
most  cases  they  are,  no  doubt,  due  to  bacterial 
septic  or  toxic  influences.  The  cause  may  also 
be  found  in  some  lesion  of  the  mucous  mem- 
brane of  the  uterus  caused  during  delivery  or 
by  some  other  interference. 

But  there  is  also  a  very  mild  form  of  purulent 
osteomyelitis  in  which  the  patient  complains  only 
slightly  of  pain  and  functional  impairment  of 
the  joints.  The  clinical  points  already  men- 
tioned before  and  the  Roentgen-ray  should  make 
the  diagnosis  positive. 

If  the  affection  is  confined  to  one  joint  only 
the  differential  diagnosis  must  decide  between 
rheumatic  (also  monarthritis  rheumatica  nodosa) , 
gonorrhoic,  syphilitic  and  uratic  monarthritis. 
In  acute  monarthritis  we  must  also  bear  in  mind 
pneumococcic  infection. 

Acute  tuberculous  monarthritis  is  sometimes 
mistaken  for  the  rheumatic  form.  The  symp- 
toms are:  a  sudden  sharp  (sometimes  only  slight) 
articular  pain  in  the  finger  or  in  the  hand,  the 
joint  is  swollen  and  its  movement  gives  pain, 
the  skin  over  it  is  hot  and  tense,  although  at 
times  there  is  no  rise  in  the  local  temperature. 
Now  if  we  find  that  the  swelling  is  of  a  doughy 
consistence  and  assumes  the  form  of  a  spina 
ventosa  and  that  the  skin  over  the  joint  has  a 


476  GENERALIZED   PAIN 

dull,  glazy  appearance  we  are  warranted  to 
decide  in  favor  of  tuberculosis,  especially  if  in 
addition  fistulous  formations  should  come  into 
evidence. 

It  is  important  to  remember  that  a  uratic 
arthritis  not  infrequently  follows  a  local  articu- 
lar injury.  There  may  have  been  a  contusion 
or  a  distortion  or  some  other  traumatic  condi- 
tion, or  pressure  from  a  narrow  shoe  or  a  cold 
of  some  sort  which  primarily  caused  the  swell- 
ing and  impaired  the  motility  of  the  affected 
joints  and  finally  degenerated  into  arthritis 
urica. 

Acute  hemarthrosis  in  hemophilia  is  our  next 
point  of  consideration.  In  this  disease  we  find 
the  development  of  a  painful  swelling  (in  the 
early  stage  the  pains  are  frequently  absent)  in 
a  joint,  chiefly  the  knee  or  elbow,  not  always 
accompanied  by  fever.  It  generally  comes  on 
after  a  cold  and  sometimes  is  preceded  by  a 
slight  traumatic  condition.  The  joint  becomes 
stiff  and  immovable,  the  hemorrhage  in  the  joint 
finds  extension  into  one  or  two  more  and  we 
soon  get  the  impression  of  an  acute  articular 
rheumatism.  If,  however,  lateral  hemorrhages 
appear  in  the  skin  and  in  the  mucous  membrane, 
the  diagnosis  is  soon  turned  in  the  right  direc- 
tion. When  these  dermal  signs  are  missing  the 
only  means  to  fall  back  on  will  be  the  anamnesis : 
is  there  inclination  to  bleeding  in  other  parts 


JOINTS  477 

of  the  body;  if  so,  is  it  a  familial  charasteristic ; 
is  the  patient  a  male,  his  age — there  are  cases 
of  hemophilia  in  females,  but  not  many — pres- 
ence of  lymphocytosis,  reduced  vascular  coagu- 
lability of  the  blood  during  the  hemophilic  hem- 
orrhages while  the  extra-vascular  coagulability 
in  the  intervals  between  the  fluxes  is  diminished? 
Gradual  return  to  normalcy  during  the  course 
of  the  disease. 

Multiple  articular  pain  without  hemorrhage 
in  the  joints  is  not  a  rarity  in  hemophilia,  in 
fact  in  every  form  of  hemorrhagic  diathesis 
(scarlet  fever,  scurvy). 

The  pains  in  the  joints  or  their  swellings  that 
accompany  hemorrhages  into  one  or  successively 
into  several  joints  may  originate  from  other 
causes,  such  as  a  spontaneous  fracture  of  the 
bones  themselves,  e.g.,  the  neck  of  the  humerus 
or  femur  through  a  local  neoplasm,  e.g.,  mye- 
loma or  neoplasmatic  metastasis.  If  motoric 
impairment  and  crackling  sounds  accede,  a  false 
diagnosis  of  acute  mon-  or  polyarthritis  may 
result.  A  careful  palpation,  however,  for  pro- 
tuberances either  at  the  injured  or  any  other 
part  of  the  affected  bones  and  the  Roentgen- 
ray  should  forestall  the  mistake. 

Acute  arthropathy  is  only  mentioned  here  as 
a  possible  source  of  the  pains  described  in  this 
department,  but  it  will  receive  more  detailed 
attention  in  the  following  chapter. 


478  GENEEALIZED  PAIN 

II.  Chronic  Articular  Pains 

Many  of  the  acute  diseases  described  in  the 
preceding  pages  often  become  chronic  in  their 
character  in  which  state  they  manifest  the  same 
morbid  conditions  and  localized  pains,  for  in- 
stance, gonorrhea,  tuberculosis,  articular  syphi- 
litic affections,  hemarthrosis  in  hemophilia  and 
scurvy.  This  refers  principally  to  those  lasting 
changes  (leading  eventually  to  ankylosis)  in 
one  joint  only  succeeding  an  attack  of  gonor- 
rhoic  or  tuberculous  articular  rheumatism  or  else 
of  hemarthrosis,  a  rather  important  symptom  in 
these  affections  of  the  joints. 

Gummatous  arthritis  is  apt  to  show  similar 
results,  for  here,  too,  we  come  across  swellings 
of  the  smaller  as  well  as  the  larger  joints  often 
involving  the  entire  head  of  the  bone.  Deform- 
ing arthritis  in  tertiary  syphilis  of  joints  must 
also  be  considered  here.  In  most  cases  chronic 
gummatous  arthritis  is  monoarticular  in  its  char- 
acter. In  both  cases  we  shall  find  light  in  the 
very  conspicuous  colateral  affection  of  the  epi- 
physis  and  periosteum,  in  the  anamnesis  (prema- 
ture births,  abortions),  in  the  nocturnity  of  the 
pains,  serologic  blood  test  and  the  results  of 
specific  treatment.  In  congenital  syphilis,  which 
may  cause  likewise  various  chronic  articular 
conditions,  the  picture  is  often  that  of  osteo- 


JOINTS  479 

chondritis,  or  a  simple  sinovitis  or  arthritis 
deformans. 

Gout  requires  special  attention  in  this  place. 
After  one,  chiefly  after  repeated  typical  attacks 
we  find  a  series  of  weaker  attacks,  but  of  longer 
duration,  with  strongly  marked  exudates  in  one 
joint;  the  painless  intervals  come  to  a  stop, 
deposits  of  uric  acid  begin  to  show  up  and  a 
crunching  sound  may  be  heard  in  the  affected 
joint;  there  is  increasing  stiffness,  motoric  inhi- 
bition and  subsequent  deformity  and  ankylosis. 
Hereditary  gout  will  be  dealt  with  in  another 
place.  I  will  only  mention  here  that  the  diag- 
nosis in  chronic  gouty  changes  of  one  or  more 
joints  is  much  assisted  by  the  evidence  of  pre- 
vious gouty  attacks. 

Chronic  hy drops  of  one,  chiefly  the  knee  joint 
— it  matters  not  whether  a  multiple  articular 
affection  has  preceded  it  or  not — should  at  once 
remind  us  of  a  tuberculous  if  not  a  syphilitic 
(congenital  or  acquired)  or  gonorrhoic  condi- 
tion, or  of  sporotrichosis,  or  of  a  chronic  osteo- 
myelitic,  para-articular  disease  of  the  bones.  In 
hemophilia  the  appearance  of  a  joint  may  be 
changed  by  hemorrhage  into  it  until  it  resembles 
a  chronic  hydrops.  This  is  particularly  the  case 
in  an  affected  knee  joint.  The  differential  diag- 
nosis in  all  these  processes  is  surrounded  by  great 
difficulties.  In  case  the  anamnesis,  the  sero- 
logic  test  and  an  attempted  diagnosis  ex  ju- 


480  GENERALIZED   PAIN 

vantibus  (anti-syphilitic  treatment)  lead  to  no 
results,  the  cytologic  and  bacteriologic  examina- 
tion of  the  articular  fluid,  or  in  some  instances 
the  X-ray  examination  of  the  joint  itself  may 
prove  successful.  But  there  are  cases  in  which 
even  the  knife  does  not  furnish  unmistakable 
proof  of  the  nature  of  this  disease. 

There  are  other  forms  of  chronic  articular 
infections  with  permanent  pains  of  varying 
intensity,  and  connected  with  inhibitory  motoric 
action,  enlargements,  changes  in  the  outlines, 
and  certain  anomalous  conditions  revealed  by 
the  X-ray  within  the  joints.  Diplococci,  staphy- 
lococci,  after-effects  of  diphtheria,  scarlet  fever, 
influenza,  etc.,  may  be  the  provoking  causes  of 
this  acute  infectious  pseudorheumatism  which 
itself  has  borne  from  the  very  beginning  the 
character  of  a  chronic  evil  or  else  degenerated 
from  the  acute  into  the  chronic  state  during  the 
course  of  the  disease.  If  the  latter  was  the 
case,  the  diagnosis  would  be  apparent,  especially 
when  supported  by  bacteriological  evidence. 

Of  the  commoner  forms  of  chronic  articular 
infections  that  are  here  concerned  it  is  as  yet  not 
possible  to  give  a  satisfactory  survey  because 
the  opinions  of  the  present  day  clinicians  vary 
so  much  as  to  their  classification  and  even  no- 
menclature. I  prefer  to  adhere  to  the  older 
system  which  looks  upon  chronic  rheumatism  of 
the  joints  as  an  atrophic  process  established  by 


JOINTS  481 

the  Roentgen-ray,  and  keeps  it  separate  from 
chronic  deforming  arthritis  which  it  considers  in 
the  light  of  a  degenerative  hyperplastic  articular 
condition.  By  this  system  the  first  named  affec- 
tion is  divided  again  into  two  subsections,  viz., 
primary  and  secondary  chronic  articular  rheu- 
matism. 

The  primary  form  which  today  is  called 
"primary  chronic  progressive  polyarthritis,"  is 
characterized  by  a  slow  creeping,  sometimes  sub- 
febrile,  but  mostly  fevereless  beginning.  It 
progresses  symmetrically  from  the  small  joints 
of  the  fingers,  toes  and  wrists.  It  has  a  chronic 
course  with  many  intervening  remissions  marked 
with  periods  of  increased  virulence  and  tempera- 
ture. The  affected  joints,  especially  the  meta- 
carpophalangeal  ones,  are  swollen  and  nodose, 
and  thickened  with  spinous  protuberances  owing 
to  the  enlargement  of  the  caps  of  the  bones  or 
in  some  rare  cases  through  articular  exudates. 
The  pain  is,  as  a  rule,  sharper  at  the  beginning 
of  the  movement  of  the  joints  which  themselves 
are  impeded  in  their  actions  if  not  rendered 
helpless  altogether.  Quick  motions  are  intensely 
painful  because  the  synovial  villi  are  constricted. 

The  most  characteristic  criterion,  however,  is 
the  contorted  shape  of  the  finger- j  oints.  The 
ungual  phalanx  is  bent  to  one  side,  the  meta- 
carpophalangeal  joint  is  abducted  towards  the 
ulna,  the  wrist  is  enlarged,  the  distal  end  of  the 


482  GENERALIZED   PAIN 

forearm  is  cylindrically  thickened.  The  toes 
also  undergo  changes.  The  big  toe  is,  as  a  rule, 
drawn  away  from  or  under  the  other  toes.  The 
skin  over  the  affected  parts  has  generally  a  paler 
tint  and  is  of  a  doughy  consistence,  but  grows 
gradually  very  thin  as  the  illness  progresses, 
seldom  sclerodermic.  Gradually  the  process 
finds  its  way  into  the  elbow  and  knee  joints. 
Ankylosis  is  one  of  the  later  symptoms.  But 
I  have  seen  cases  in  which  this  affection,  eschew- 
ing slowness,  settled  with  savage  rapidity  and 
sudden  feverish  attacks  simultaneously  in  sev- 
eral of  the  small  joints. 

In  the  secondary  I  comprise  every  other  form 
of  chronic  articular  rheumatism  which  had  for 
a  precursor  an  attack  of  undoubted,  typical 
acute  rheumatic  polyarthritis.  This  secondary 
form  does  often  present  the  manifestations  de- 
scribed in  the  previous  paragraph.  More  fre- 
quently, however,  the  result  is  a  chronic  fibrous 
ankylosed  rheumatism,  i.e.,  in  one  or  more  joints 
enlargements  of  the  caps  appear,  also  of  the 
lateral  ligaments  of  the  joints  and  their  ten- 
dons until  a  complete  fusion  into  one  solitary 
fibrous  mass  is  formed  causing  complete  rigidity 
and  ankylosis.  This  transformation  may  con- 
tinue after  the  symptoms  of  acute  rheumatism 
have  already  disappeared  if  it  has  not  completed 
its  course  during  the  progress  of  the  disease. 

The  differentiation  between  the  secondary  and 


JOINTS  483 

primary  form  rests  principally  on  the  history 
of  the  case  and  the  nature  of  the  articular 
changes  which  are  distinctly  characteristic  for 
both  affections.  It  is  well  to  remember  that 
after  an  attack  of  acute  articular  rheumatism 
pains  will  reappear  in  the  affected  joints  from 
time  to  time — often  for  years — influenced  gen- 
erally by  metoreological  conditions,  likewise 
painful  minor  swellings  and  stiffness  which  may 
put  the  joint  temporarily  out  of  commission 
until  the  normal  state  is  gradually  reached  again. 

The  second  form  of  classical  chronic  affections 
of  the  joints  is  hypertrophic  arthritis,  more  accu- 
rately called  deforming  osteoarthritis.  It  runs 
a  slow,  sneaking  course,  is  not  very  painful  and 
does  not  interfere  much  with  the  motility  of  the 
joints  until  later  on  in  life.  It  may  be  also 
polyarticular  in  its  nature  and  attack  the  smaller 
joints  (especially  in  the  spine).  As  a  rule,  it 
affects  at  first  only  one  of  the  larger  joints, 
the  hip,  shoulder,  knee  or  the  big  toe,  but  sprouts 
out  from  there  into  the  other  larger  joints. 
Anatomical  as  well  as  radiological  examination 
shows  onion  formations,  which  naturally  affect 
the  motoric  faculties  of  the  joints  more  and  more 
until  the  latter  become  quite  immovable  and 
very  much  deformed.  Cardiac  complications 
are  rare  whilst  in  chronic  rheumatism  they  are 
ever  plentiful. 

There  is  another  distinguishing  sign  to  which 


484  GENERALIZED   PAIN 

I  desire  to  call  attention.  In  both  the  afore- 
mentioned principal  forms  of  chronic  articular 
disease  the  pains  are  generally  aggravated  by 
any  movement  of  the  affected  joint,  whilst  in 
the  initial  stages  of  chronic  articular  rheumatism 
and  of  deforming  arthritis  the  pains,  as  a  rule, 
start  with  the  transition  from  rest  into  activity 
of  the  joint,  is  most  acute  during  the  first  few 
movements  but  declines  in  virulence  or  disap- 
pears altogether  with  continued  exercise.  An- 
other important  sign  in  deforming  arthritis— 
in  fact  in  every  painful  anatomical  joint  disease 
— is  this:  a  knock  or  a  stroke  on  the  elbow 
produces  pain  in  the  corresponding  shoulder;  in 
deforming  omarthritis  a  kick  on  the  heel  or  a 
slap  on  the  sole  of  the  foot  or  on  the  bent  knee 
elicits  a  similar  pain  in  the  hip  joint.  This  same 
distinguishing  sign  is  also  found  when  in  de- 
forming arthritis  the  pain  radiates  into  the  entire 
extremity  with  demonstrable  tenderness  on  pres- 
sure of  the  nerve  roots  thus  simulating  an  ischio- 
or  brachial  neuralgia.  The  decision  should  not 
be  hard  to  make  for  it  is  easy  to  see  that  this 
overlapping  painful  zone  really  emanates  from 
the  joint.  Moreover  in  neuralgia  the  joint  can 
still  be  used  although  with  discretion. 

Chronic  articular  rheumatism  due  to  ochrono- 
sus  deserves  special  mention.  The  presence  of 
homogentisic  acid  is  the  cause  of  this  trouble 
as  well  as  of  chronic  endocarditis  which  so  fre- 


JOINTS  485 

quently  accompanies  it.  The  evidence  of  exist- 
ing alcaptonuria  and  dysuria  facilitates  the 
diagnosis. 

Gout  must  be  our  next  subject  of  considera- 
tion. The  chronic  condition  of  this  disease 
evolves  from  one  or  more  preceding  acute  at- 
tacks, a  fact  upon  which  the  positive  diagnosis 
must  rest.  In  both  forms  we  should  look  for 
crepitant  rales  in  the  affected  joints,  especially 
the  knee-joint,  for  chronic  inflammatory  changes 
in  the  joints  due  to  deposits  of  uric  acid,  and 
to  subsequent  deformities,  structural  anomalies 
and  ankylosed  conditions.  Uratic  deposits  in 
the  softer  parts  around  the  joints  (tophi)  are 
often  the  causative  factor  of  these  changes.  The 
fingers  appear  swollen  or  thickened  in  certain 
parts  and  twisted  out  of  shape,  the  wrists  ulnad. 
The  toes,  especially  the  metatarsophalangeal 
joint  of  the  big  toe,  are  bent  in  a  devious  man- 
ner under  the  other  toes,  thus  forming,  as  it 
were,  a  foundation  for  them.  This  abnormal 
position  may,  however,  be  due  to  chronic  articu- 
lar rheumatism  or  to  ill-fitting  shoes.  The  pres- 
ence of  gouty  nodes  would  be  clinical  evidence. 

These  nodes  are  often  found  on  the  helix  of 
the  ear,  but  chiefly  around  the  joints,  with  pref- 
erence about  the  olecranon.  They  rise  from 
the  subcutaneous  tissue,  from  the  synovial  sacs, 
rarely  from  the  periosteum  or  the  nerve  proc- 
esses and  develop  gradually  but  without  causing 


486  GENERALIZED   PAIN 

pain.  If  their  origin  is  derived  from  any  other 
source  they  may  be  recognized  by  sliding  them 
about  over  the  bone.  Otherwise  the  diagnosis 
can  be  made  from  their  soft,  doughy  feeling 
and  by  needling  a  young  tophus  when  a  white, 
chalky,  mushy  mass  exudes  which  consists  essen- 
tially of  uric  acid  and  its  salts.  This  is  also  the 
case  when  this  exudation  breaks  spontaneously 
through  the  skin  leaving  a  scar  in  the  place  of 
the  former  fistula.  Beneath  the  scar  prickly 
points  or  horns  may  be  felt. 

If  the  nodes  are  stony  hard  the  diagnosis  may 
be  rather  difficult  to  make  owing  to  the  fact  that 
such  protuberances  are  also  observed  in  chronic 
articular  rheumatism.  (The  differentiation  be- 
tween these  and  Heberden's  nodes  will  be  dis- 
cussed later  on.)  In  such  a  case  it  is  wise  to 
fall  back  on  the  Roentgenogram,  the  blood  test 
for  uric  acid  after  a  purin-free  diet. 

Notice  also  that  the  morbid  conditions  of  the 
joints  in  chronic  gout  are  quite  abnormal  and 
so  different  from  those  prevailing  in  chronic 
rheumatism:  in  the  latter,  simultaneous  and  sym- 
metrical attacks  and  an  even  disfiguration  of 
several  joints,  in  gout,  asymmetry  of  the  joints, 
affection  of  one  joint  only,  perhaps  nodes  on 
only  one  joint  thus  making  the  asymmetrical 
appearance  of  the  various  joints  more  drastic. 

In  gout  the  crepitus  (especially  in  the  knee- 
joint)  is  more  like  the  crackling  sound  over  the 


JOINTS  487 

lungs,  while  in  chronic  articular  rheumatism  it 
is  of  a  coarser  character  and  sounds  more  like 
friction  or  large  bubbles  exploding.  This  is 
particularly  the  case  in  deforming  arthritis.  If 
the  pains  are  felt  more  acutely  during  the  night 
time  and  begin  to  tone  down  towards  morning 
it  speaks  rather  for  gout,  because  in  chronic 
rheumatism  the  painfulness  awakens  with  the 
sleeper's  first  movements  as  he  tries  to  rise  from 
the  couch.  Nevertheless  these  conditions  are 
sometimes  reversed  in  different  patients. 

Of  course  these  are  clinical  points  which  estab- 
lish the  genesis  of  a  gouty  affection:  such  as 
hereditary  conditions,  the  life  led  by  the  patient, 
preceding  or  concomitant  manifestations  of 
chronic  gout,  chronic-uratic  diathesis,  the  patient 
is  subject  to  catarrh  in  the  air  passages  or  to 
asthmatic  attacks,  to  iritic  or  sclerotic  affections, 
dyspeptic  or  neuralgic  troubles,  localized  pains, 
e.g.,  achillodynia  or  tarsalgia,  cramps  in  the 
calves,  eczema,  hemorrhoids,  glycosuria,  con- 
tracted kidney  and  nephrolithiasis,  likewise  in- 
creased uric  acid  content  in  the  venous  blood 
even  with  a  purin-free  diet. 

The  assumption  that  severe  pains  in  the  big 
toe  point  to  a  gouty  affection  often  enough  leads 
to  a  mistaken  diagnosis  and  wrong  therapeutic 
measures.  Frequently  what  is  taken  for  gout  is 
only  a  case  of  chronic  arthritis  caused  by  the 
(wearing  of  shoes  which  are  too  narrow  or  pointed 


488  GENERALIZED   PAIN 

at  the  toes — more  often  observed  in  women. 
The  tightly  fitting  footwear  forces  the  big  toe 
into  a  valgus  position,  the  metatarso-phalangeal 
joint  is  misshapen  and  the  synovial  villus  is 
badly  squeezed  in.  The  resulting  pains  strongly 
resemble  those  caused  by  gout,  and  yet  a  narrow 
boot  may  arouse  a  gouty  attack  from  its  slum- 
bers. 

That  periarticular  gouty  tophi  are  apt  to  be 
mistaken  for  Heberden's  nodes  is  only  men- 
tioned here.  The  subject  will  be  discussed  more 
fully  later  on.  To  take  a  cutaneous  tophus 
erroneously  for  a  cystic  growth  or  a  small  ab- 
scess or  a  milium,  or  else  for  a  ganglion  if  seated 
in  a  synovial  sac,  seems  to  me  well  nigh  impos- 
sible if  a  careful  inspection  is  made.  The  error 
might  be  pardoned  when  concretions  on  the 
helix  are  observed  which  may  be  a  congenital 
malformation  on  the  ear,  or  a  cartilagenous 
defect  caused  by  frostbite  resembling  a  patho- 
logical condition.  The  microscopic  examination 
of  the  tissue  and  the  anamnesis  should  remove 
any  false  impression. 

Sebaceous  cysts  form  sometimes  on  the  car- 
tilage of  the  ear  and  may  be  misinterpreted  for 
gouty  nodules,  but  it  is  easy  to  distinguish  be- 
tween them  as  the  former  are  softer  to  the  touch 
and  are  seated  in  the  subcutaneous  cellular  tissue, 
while  the  gouty  formations  are  harder  and  sprout 
from  the  cartilage  with  which  they  even  coalesce 


JOINTS  489 

as  they  grow  older.  On  palpation,  it  seems  to 
me,  the  sebaceous  cyst  presents  a  hard  but  uni- 
formly smooth  surface  whilst  the  gouty  tophi 
have  more  of  a  sandy  feel  in  them.  If  in  doubt 
the  chemical  test  will  decide  the  presence  of 
uratic  contents. 

There  are  cases  in  which  we  find  a  combina- 
tion of  both  diseases,  viz.,  chronic  gout  and 
chronic  rheumatism  of  the  joints.  In  these 
cases  the  gouty  affections  generally  select  those 
joints  in  which  the  rheumatic  virus  has  already 
settled.  An  early  uratic  diathesis  often  lays 
the  foundation  for  chronic  articular  rheumatism 
or  gout  in  later  years.  When  I  use  here  the 
expression  "chronic  articular  rheumatism"  I 
mean  only  that  affection  which  is  entirely  free 
from  gouty  symptoms  and  presents  purely  the 
typical  features  of  the  disease.  In  many  cases 
of  this  kind  I  could  find  no  therapeutic  results 
whatever  from  the  administration  of  antiuratic 
remedies,  whilst  they  reacted  promptly  to  the 
measures  which  it  is  customaiy  to  apply  in 
chronic  rheumatism. 

It  is  by  no  means  an  uncommon  occurrence 
in  every  day  practice  to  come  across  cases  of 
chronic  uratic  diathesis  in  which  complaints  of 
chronic  pains  in  almost  any  possible  joint  are 
ripe.  And  yet  a  most  careful  scrutiny  discloses 
no  crepitus  or  deformity,  not  to  speak  of  gouty 
tophi.  Here  it  is  wise  to  be  guided  by  the  hered- 


490  GENERALIZED   PAIN 

itary  and  constitutional  idiosyncrasies  of  these 
chronic  sufferers.  The  diagnosis  must  depend 
rather  upon  a  reliable  blood  test  than  the  cus- 
tomary overestimated  examination  of  the  urine 
which  from  the  standpoint  of  present  day  science 
is  of  a  minor  significance  in  these  cases.  Copious 
residue  of  the  largest  possible  amount  of  uric 
acid  and  diminished  Zerner's  coefficient  can  at 
the  very  best  only  suggest  the  thought  of  gout. 

Basedow's  disease,  hyperthyreoidism  will  in 
some  rare  instances  be  found  associated  with 
typical  chronic  progressive  polyarthritis  with 
exudations  in  the  joints  and  must  be  looked 
upon  as  a  thyreoprival  affection  which  compli- 
cates the  disease  but  not  the  diagnosis. 

Gout  may  be,  according  to  some  authors, 
associated  with  a  second  metabolic  anomaly,  viz., 
oxalemia  and  oxdluria.  They  also  combine  with 
diabetes  mellitus  and  obesity.  The  clinical  signs 
are  claimed  to  be  abnormal  fatigue,  chronic  dys- 
peptic and  neurasthenic  troubles,  kidney  colics, 
albuminuria,  hematuria  and  chronic  pains  in  the 
joints.  The  proof  for  its  existence  is  to  be 
found  in  the  exaggerated  amount  of  oxalic  acid 
in  the  blood  equal  to  from  three  up  to  ten  times 
above  the  normal  content  which  is  at  the  utmost 
1  eg.  in  1000  ccm. 

Chronic  articular  affections  are  often  com- 
bined with  psoriasis  (arthropathia  psoriatica) . 
(This  does  not  refer,  however,  to  isolated  pains 


JOINTS  491 

in  the  joints  in  the  shape  of  mere  acute  after- 
effects.) I  am  not  able  to  give  a  correct  classi- 
fication of  this  subdivision  of  articular  affections. 

Chronic  swellings  in  the  joints  come  under 
our  observation  sometimes  during  the  course  of 
scleroderrma.  Patients  afflicted  with  myxedema 
(thyreoprival  articular  rheumatism)  complain 
of  chronic  pain  in  the  joints  of  the  hands  and 
feet.  We  find  the  same  condition  also  in  adre- 
nal affections  (Addison's  disease ~,  tumors).  Ar- 
ticular changes  have  also  been  reported  in 
myositis  ossificans,  in  osteopsatyrosis  and  in 
Paget's  ostitis.  Their  genesis  has  never  been 
properly  cleared  up  and  I  myself  cannot  speak 
from  personal  experience  regarding  them. 

On  the  other  hand  chrome  tuberculous  articu- 
lar diseases  are  of  greater  importance.  The 
diagnosis  will  find  much  help  in  the  considera- 
tion of  the  regular  tuberculous  symptoms  such 
as  the  usual  manifestations,  swelling  in  the 
glands,  anal  fistulae,  comptodactylia  in  the  ring- 
finger,  reaction  to  tuberculin  and  perhaps  a 
complementary  restringent  reaction.  There  is 
a  distinct  difference  between  this  and  the  com- 
mon chronic  articular  rheumatism.  The  former 
begins,  as  a  rule,  in  the  larger  joints,  the  knees 
and  the  hips,  but  when  it  reaches  the  finger 
joints  the  spindle  formed  swellings  make  their 
appearance  rather  in  the  joint  between  the 
middle  and  ungual  phalanx,  whilst  in  ordinary 


492  GENERALIZED   PAIN 

chronic  articular  rheumatism  the  joint  between 
the  proximal  and  middle  phalanx  is  affected. 
And  again,  in  the  tuberculous  form  the  promi- 
nence comes  into  view  in  only  one  finger,  when 
in  the  other  several  or  all  the  fingers  are  simul- 
taneously attacked.  The  Roentgen  picture 
shows  highly  marked  differences  between  the 
two.  Chronic  syphilitic  articular  rheumatism 
(pseudotumor  albus  lueticus)  is  another  possi- 
bility that  requires  our  attention  in  this  connec- 
tion. 

Nervous  Affections  of  the  Joints 

Patients  troubled  with  hemiplegia  are  wont 
to  complain  of  pains  which  come  on  either  spon- 
taneously or  by  passive  movements  mainly  in 
the  shoulder  joints.  They  are,  no  doubt,  due 
to  a  tension  of  the  capsular  ligaments  caused 
by  the  dead  weight  of  the  paralyzed  arm,  for 
they  disappear  when  the  arm  is  properly  sup- 
ported. 

Analogous  pains  are  felt  in  the  spinal  cord 
in  poliomyelitis,  but  in  tabes  and  syringomyeUa 
the  pains  are  of  a  different  kind.  Here  they 
settle  with  special  viciousness  principally  in  the 
joints  of  the  larger  extremities.  The  diagnosis 
is  rendered  more  difficult  by  the  fact  that  these 
pains,  like  all  lancinating  pains  are  largely  in- 
fluenced by  weather  conditions,  damp,  clammy 
days  being  the  worst  offenders.  The  conven- 


JOINTS  493 

tional  symptoms  of  myelonal  affections  should, 
however,  correct  any  possible  error  as  to  their 
true  nature. 

Cerebral  diseases  of  a  hemiplegic  character 
are  also  guilty  of  producing  articular  pains 
which  are  felt  along  the  lines  of  the  nerve  paths 
in  the  corresponding  half  of  the  body  or  its 
extremities.  Sometimes  they  are  continuous, 
sometimes  intermittent,  neuralgiform  in  char- 
acter. Sometimes  they  are  precursors  or  com- 
panions of  locomotor  paresis  and  at  other  times 
they  follow  in  the  wake  of  it.  The  diagnosis 
is  fully  given  in  the  chapter  on  "Pains  in  the 
Extremities."  In  spastic  hemiplegia  the  pains 
may  also  be  due  to  a  change  in  the  static  ele- 
ment of  the  joint  caused  by  the  increased 
muscular  tonus. 

In  chronically  diminishing  muscle  tonus  (atro- 
phies and  tabes)  articular  changes  and  pains 
develop  in  a  similar  manner. 

The  trophic  disturbances  in  the  joints  which 
manifest  themselves  in  arthropathies,  in  tabes 
and  syringomyelia  are  the  natural  progeny  of 
other  diseases  in  the  central  nervous  system. 
Their  resemblance  to  deforming  osteo-arthritis 
and  to  chronic  articular  rheumatism,  especially 
in  syringomyelia,  is  so  pronounced  that  even 
prominent  neuropathalogists  are  at  times  misled 
into  a  false  diagnosis.  This  is  principally  due 
to  the  fact  that  the  arthropathy  whose  seat  is 


494  GENERALIZED  PAIN 

as  a  rule  in  the  upper  extremities,  i.e.,  shoulder 
and  elbow  joints,  does  not  come  on  suddenly 
but  very  slowly  and  is  one  of  the  first  symptoms 
of  the  disease  and  at  a  time  when  the  sensibility 
of  the  joints  is  still  unimpaired.  The  patient 
complains  of  pain  in  the  affected  parts  while 
arthropathy  is  still  in  the  hypertrophic  stage  in 
which  the  swelling  of  the  joint  terminals  and 
the  osseous  new  growths  in  the  articular  capsules 
are  only  beginning  and  even  exostosis  on  the 
diaphyses  is  forming. 

On  the  other  hand  there  is  always  the  risk 
of  mistaking  the  swellings  in  the  finger  joints 
due  to  syringomyelia  for  a  symptom  of  chronic 
articular  rheumatism.  To  avoid  this  error  we 
must  look  closely  for  muscular  atrophies,  trophic 
conditions  in  the  fingers,  painless  whitlows, 
scoliosis,  spastic  paresis  in  the  lower  legs,  and 
bulbar  symptoms  the  most  important  of  which 
is  dissociated  insensibility  to  pain. 

It  is  much  easier  to  differentiate  between 
tabetic  arthropathy  and  deforming  arthritis.  The 
former  comes  on  suddenly  with  large,  painless 
swellings  in  the  joints  that  may  extend  over  the 
whole  extremity.  It  may  also  follow  on  the 
heels  of  paresthesias  in  the  articular  region  or 
in  the  joints  themselves.  The  presence  of  free 
bodies  in  the  joints  unaccompanied  by  pain, 
grating  on  motion  and  crackling  sounds  are 
characteristics.  The  lower  limbs  are  the  favorite 


JOINTS  495 

site  for  attack  in  tabetic  arthropathy,  i.e.,  the 
knee,  foot  and  hip  joints,  but  when  the  shoulder 
is  also  involved  tabes  superior  is  rather  indicated. 
The  X-ray  and  the  usual  typical  symptoms  are 
the  proper  aids  for  a  good  diagnosis.  Sponta- 
neous fractures  or  infractions  should  not  be 
overlooked. 

It  may  be  of  interest  to  mention  here  that 
loose  joints  are  often  the  consequence  of  acute 
articular  rheumatism  and  mongolism,  undoubt- 
edly due  to  an  anomalous  development  of  the 
articular  cartilages. 

Diseases  of  the  nervous  system  not  only  lead 
to  anatomical  changes  in  the  joints  but  also  to 
arihralgias  and  multiple  sclerosis. 

In  neurasthenia  the  pain  is,  as  a  rule,  less 
intensive  but  rather  of  a  dragging,  pressing, 
or  burning  kind.  Often  it  consists  simply  of 
an  aching  tired  feeling.  Bodily  motion  softens 
or  suppresses  it  altogether,  whilst  in  chronic 
articular  rheumatism  the  pain  is  sharpened 
thereby,  although  I  must  admit  that  here,  too, 
the  change  from  rest  into  activity  in  the  latter 
case  only  awakens  the  pain  sometimes  which 
tones  down  again  and  gradually  disappears 
under  continued  exercise.  Of  course,  it  goes 
without  saying  that  radiological  articular  changes 
are  not  observed  in  neurasthenia. 

The  epileptic  patient  suffers  also  from  pains 
in  the  joints  during  the  interparoxysmal  period. 


4?96  GENERALIZED   PAIN 

Hysteria  is  another  fertile  ground  for  these 
pains,  with  preference  in  the  lower  extremities 
and  more  often  due  to  some  slight  traumatic 
influence.  If  the  attacks  continue  for  some  time 
a  permanent  fixation  of  the  affected  joint  may 
be  the  result,  atrophy  of  the  surrounding  mus- 
cles may  also  set  in  with  secondary,  trophic, 
anatomical  changes  in  the  articular  portion. 
This  makes  it  rather  difficult  to  differentiate  it 
from  organic  articular  affections.  But  the  fol- 
lowing points  will  be  of  great  assistance:  the 
skin  over  the  affected  part  has  an  hyperalgesic 
appearance,  the  sense  of  pain  is  reduced  by 
distraction,  the  latter  also  allows  of  motions 
which  seemed  impossible  before,  the  pains  are 
sharpened  when  sympathy  is  shown  the  patient, 
if  the  head  of  the  joint  is  pressed  firmly  against 
the  acetabulum  no  pain  is  felt,  but  a  slight 
touch  of  the  skin  over  it  is  exceedingly  painful. 
Naturally  the  X-ray  is  a  great  help  in  the 
diagnosis  of  these  cases.  Still  we  must  never 
lose  sight  of  the  fact  that  even  hysterical  persons 
may  be  afflicted  with  anatomical  lesions  of  the 
joints. 

In  some  cases  these  articular  pains  without 
manifest  hysterical  or  neurasthenic  stamp  appear 
as  true  articular  neuralgias,  that  are  sometimes 
accompanied  by  vasomotoric  changes  in  the 
joints.  One  patient  complains  of  pains  in  the 
joints  when  he  is  walking,  another  claims  that 


JOINTS  497 

the  pains  disappear  when  he  is  moving  about. 
Of  importance  for  the  diagnosis  of  such  cases 
is  the  finding  of  pressure  points  and  hyperes- 
thesia  of  the  skin  over  the  articulation,  espe- 
cially when  symptoms  of  an  angioneuritic  char- 
acter, or  fever — articular  inflammation  or  gout 
— are  present. 

In  tabes  dorsalis  arthralgias  may  also  be 
observed,  quite  independently  of  arthropathy. 
They  arrive  in  sudden  attacks,  persist  for  sev- 
eral days,  sometimes  for  a  whole  week,  are 
located  in  the  joints  of  the  big  toe  but  radiate 
thence  into  other  joints,  and  the  affected  parts 
feel  hot,  so  to  speak,  a  veritable  "tabetic  pseudo- 
gout."  True  gout  generally  comes  on  after 
midnight,  but  these  tabetic  arthropathies  seem 
to  prefer  the  time  before  or  close  to  that  period. 
Objective  tabetic  symptoms  should  clear  up  the 
situation. 

Similar  chronic  arthralgias  with  local  hyper- 
esthesia  of  the  skin  may  also  follow  in  the  wake 
of  chronic  obstipation  (autointoxication).  Re- 
move the  cause  and  the  symptoms  will  disappear. 

The  case  is  different  in  articular  pains,  espe- 
cially in  the  hip  or  knee,  which  arises  from 
affections  in  the  small  pelvis  or  in  the  abdomen 
nearest  the  hip  such  as  hemorrhoids,  diseases  of 
the  rectum,  the  uterus,  the  bladder,  the  prostate 
or  in  chronic  appendicitis,  and  are  felt  in  walking 
or  other  bodily  exercises,  sometimes  also  during 


498  GENERALIZED   PAIN 

the  night  or  when  resting.  Objective  changes 
in  the  joints  are  rarely  found,  but  sometimes  a 
slight  congestion  or  a  crunching  sound  in  the 
joint  may  be  noticed.  However,  muscular  fixa- 
tion, sensitiveness  to  pressure,  an  exquisite  ten- 
derness of  the  skin  just  over  the  affected  joint, 
in  fact  in  the  whole  field  of  the  morbid  segment 
and  its  corresponding  nerve  complex  (n.  ischia- 
dicus,  cruralis,  saphenus)  as  well  as  paresthesias 
may  be  expected. 

Certain  arthralgias  may  also  parade  as  masked 
malaria,  while  other  recidivous  forms  spring 
from  a  chronic  osteomyelitic  focus  near  to  the 
affected  joint.  In  rachitis  tar  da  we  likewise 
hear  complaints  of  articular  pains  coupled  with 
unusual  fatigue.  Proof  of  hyperostosis  (rosary 
formation)  on  the  ribs,  of  genu  valgum  (both, 
however,  of  recent  origin  only),  skiagrams  of 
the  bones,  also  the  examination  of  lime  balance 
should  be  winning  features  when  forming  the 
diagnosis. 

Of  great  importance  is  the  fact  that  arthral- 
gias are  a  prominent  symptom  of  lead  poisoning. 
The  blue  line,  clonus,  the  punctated  erythrocytes, 
etc.,  are  the  residual  signs. 

Lead  is  a  strong  factor  in  many  severe  arti- 
cular changes,  e.g.,  lead  gout,  gouty  tophi,  gouty 
kidney. 

A  predisposition  to  gout  is  often  the  road 
that  leads  to  arthralgias,  or  rather  to  articular 


JOINTS  499 

pain  even  though  demonstrable  and  definable 
changes  in  the  joints  themselves  are  not  appar- 
ent. Long  before  the  real  attack  comes  on, 
even  before  clear  clinical  signs  of  gout  are  ob- 
served, these  cases  will  complain  of  transient, 
recurrent  pains,  lasting  sometimes  for  days,  in 
various  joints  or  in  one  only,  especially  during 
changes  in  the  weather.  Purin  tests,  hereditary 
familial  traits,  observation  of  habitus  in  eating 
and  living  should  be  guiding  points. 

Arthralgias  (toxic)  as  accompanying  symp- 
toms in  chronic  uremia  are  of  rare  occurrence. 
Objective  sensitiveness  upon  pressure  on  the 
joints  may  prevail — it  may  also  be  absent.  The 
seat  of  the  pains  (often  intermittent)  may  be 
paraarticular.  Whether  there  is  an  anatomical 
subtratum  for  these  arthralgias  I  am  not  pre- 
pared to  claim.  But  I  can  say  this,  that  in 
none  of  my  cases  the  articular  pains  were  in 
the  foreground,  they  were  always  surpassed  by 
the  other  morbid  sufferings  and  in  consequence 
never  an  obstacle  to  the  diagnosis. 

Strictly  distinct  from  these  are  the  cases  of 
true  articular  gout  due  to  the  retention  of  uric 
acid  due  to  a  preexisting  primary  or  secondary 
granulation  of  the  kidney.  The  differential 
diagnosis  is  selfevident. 

Articular  pains  come  also  to  the  surface  dur- 
ing the  climacterium  and  in  the  adolescent  period 
in  girls. 


500  GENERALIZED   PAIN 

In  adiposis  dolorosa  they  often  make  move- 
ment painful  owing  to  the  fatty  deposits  in  the 
joints  which  are  also  very  sensitive  to  pressure. 

In  insufficiency  of  the  thyreoid  the  articular 
pains  are  outstripped  by  the  other  clinical  signs. 

Acute  arthralgias  are  common  in  a  whole 
series  of  acute  infectious  diseases,  especially  in 
their  incipient  stages,  in  all  infectious  pseudo- 
rheumatisms  and  in  the  Wolhynian  fever. 

Intermittent  articular  hydrops  deserves  men- 
tion here.  It  is  partially  due  to  nervous  influ- 
ences but  also  connected  with  acute  swelling  in 
the  affected  joint  or  joints.  As  a  partial  symp- 
tom of  hydrops  hypostrophos  (Quinke's  angio- 
neurotic  edema)  (probably  due  to  regional 
venous  cramps),  it  appears  at  times  in  exchange 
with  other  manifestations  of  "exudative  dia- 
thesis" .asthma,  urticaria,  mucous  colic,  vaso- 
motoric  rhinitis,  etc.),  sometimes  also  as  an 
isolated  condition,  but  principally  in  one  of  the 
kneejoints  or  in  both  (hydrops  genus  intermit- 
tens),  or  in  some  instances  in  one  knee  joint  and 
one  or  more  joints  in  different  parts  of  the  body. 
Fever  or  chills  are  rarely  present,  but  often  a 
sudden  and  considerable  infiltration  in  the  af- 
fected parts  may  be  observed.  This  may  not 
be  inhibiting  movement  and  quite  painless, 
while  in  some  cases  the  pains  are  very  severe; 
and  again,  whilst  in  some  cases  there  is  a  rise 
in  temperature  and  the  skin  over  the  affected 


JOINTS  501 

joint  is  reddened,  in  other  cases  it  does  not  lose 
its  normal  aspect.  The  course  of  the  disease 
is  about  8  days.  In  some  women  it  sets  in 
regularly  before  every  menstrual  flux;  in  other 
patients  it  appears  with  regular  periodicity. 
The  symptoms  should  be  ample  for  the  diagnosis. 

But  we  must  not  forget  that  a  hydrops  chro- 
nicus  articulorum  and  not  any  the  less  an  inter- 
mittent hydrops  articularis  (the  latter  is  also, 
as  a  rule,  the  manifestation  of  an  idiopathic 
vasomotoric  neurosis)  may  sometimes  be  only 
a  deuteropathic  disease.  It  is  found,  though 
rarely,  in  company  with  arthropathies  in  tabes 
and  syringomyelia,  with  Easedow's  disease  and 
polycythemia,  but  may  also  be  (but  only  when 
in  an  independent  state)  the  expression  of  a 
tuberculous  or  heredo-syphilitic,  more  frequently 
of  a  gonorrhoic  affection.  Hydrops  artic.  inter- 
mittens  of  a  joint,  e.g.,  in  the  knee,  may  also 
be  caused  and  sustained  by  a  chronic  osteo- 
myelitis. The  fact  that  in  every  instance  only 
one  joint  is  affected  and  the  X-ray  should  be 
sufficient  for  proper  recognition.  In  neurotic 
hydrops  the  affection  settles  now  in  this,  but  the 
next  time  in  the  contralateral  joint. 

Heberden's  nodes,  about  the  size  of  a  small 
pea,  are  always  connected  with  chronic  arthritis 
or  chronic  gout.  They  develop  on  the  proximal 
extremity  of  the  ungual  phalanx  on  the  dorsal 
side  of  the  finger,  preferably  the  little  finger, 


502  GENERALIZED   PAIN 

either  on  one  or  both  sides,  are  not  always  soft 
but  of  different  degrees  of  hardness,  rather 
painful  and  tending  to  become  paresthetic. 
Their  presence  impairs  the  motility  and  gradu- 
ally bends  them  in  a  solar  or  radial  direction. 
As  companions  of  gout  or  chronic  arthritis  they 
are  common  enough,  but  there  is  an  intimate 
connection  between  them  and  an  impairment 
of  the  genital  functions  such  as  the  climacterium 
or  the  surgical  removal  of  some  internal  genital 
organ. 

The  differentiation  between  Heberden's  nodes 
and  periarticular  gouty  nodes  is  not  difficult, 
unless  the  latter  grow  out  from  the  periosteum 
or  the  tendon  roots  in  which  case  there  is  patent 
motility  in  the  bones  while  in  the  Heberden's 
nodes  there  is  none.  In  gouty  nodes  consistence 
and  touch  are  telling  signs;  they  have  an  elastic 
hardness  of  a  granular,  gravelly,  warty,  prickly 
quality,  while  the  hardness  in  Heberden's  nodes 
has  a  more  even  smoothness  especially  when 
they  get  older. 

The  seat  of  the  affection  differs  strongly  in 
both.  Heberden's  nodes  choose  the  ungual  pla- 
lanx  particularly  of  the  little  finger;  the  gouty 
nodes  and  other  articular  affections  prefer  the 
pedal  extremities,  with  predilection  the  big  toe. 
In  chronic  gout  or  after  acute  gouty  attacks 
these  nodes  are  formed — but  not  exclusively — 
on  the  big  toe,  as  they  appear  in  other  joints 


JOINTS  503 

of  the  lower  extremities  as  well.  The  X-ray 
plainly  shows  a  marked  difference  between  the 
kinds  of  nodes.  It  is  my  experience  also  that 
Heberden's  nodes  which  stand  in  causative  con- 
nection with  gout  and  arthritis  are,  forsooth, 
much  more  painful  in  themselves  as  well  as 
sensitive  to  pressure,  than  those  which  follow 
upon  impaired  genital  function. 

Chronic  arthritis  of  a  very  painful  character 
is  quite  common  in  stout,  fat  women  of  the 
climacteric  age. 

Observe  also  that  in  this  disease  nodular  for- 
mations resembling  the  gouty  nodes  will  appear 
under  the  skin.  The  X-ray  will  plainly  show 
the  difference  between  them.  (Rheumatismus 
articulorum  nodosus  ckromcus  as  against  rheu- 
matismus  artic.  nodos.  acut.)  Spontaneous  pain 
speaks  for  gouty  and  against  rheumatic  nodes. 

A  similar  affection  is  comptodactylia.  It  con- 
sists of  excrescences  on  the  side  of  the  bones  of 
the  medial  phalanx,  only  at  times  painful.  They 
assume  sometimes  spindle-shaped  figures  around 
the  medial  phalanx  and  seem  to  come  into  evi- 
dence with  disturbances  in  the  intestinal  canal 
only  to  disappear  again  when  the  cause  has  been 
removed.  I  have  never  seen  a  case  myself. 

A  disease  of  the  central  nervous  system  which 
is  often  erroneously  taken  for  chronic  arthritis, 
in  fact,  at  the  first  glance  strongly  resembles  it, 
is  paralysis  agitans.  The  fingers  frequently 


504  GENERALIZED   PAIN 

show  the  same  position  to  the  hand  in  both  dis- 
eases, i.e.,  turned  towards  the  ulna.  Moreover, 
the  patient  not  seldom  complains  in  paralysis 
agitans  of  rheumatic  pains  in  the  extremities, 
and  in  both  affections  the  .tendon  reflex  is  in- 
creased. These  circumstances  make  allowance 
for  the  error.  But  in  paralysis  agitans  we  fail 
to  find  those  changes  in  the  configurations  of 
the  joints  which  are  such  salient  features  in 
chronic  arthritis.  We  miss  the  swelling,  the 
impaired  motility  of  the  joints  between  the 
ungual  and  middle,  and  also  between  the  middle 
and  metacarpal  phalanges  so  characteristic  in 
chronic  arthritis. 

As  for  the  rest  the  special  symptoms  of  par- 
alysis agitans  should  be  a  sure  basis  for  the 
diagnosis,  viz.,  ague,  muscular  rigidity  and  the 
bodily  posture  of  the  patient.  Put  there  are 
cases  in  which  both  diseases  may  simultaneously 
exist. 

It  is  easier  to  avoid  another  error.  The  pa- 
tient complains  of  stiffness  in  the  joints  and 
difficulty  in  moving  them.  "Chronic  arthritis" 
is  the  first  thought.  But  the  real  cause  will  be 
found  in  the  skin  which  is  drawn  taut  by  sclero- 
dermia,  has  lost  its  softness  and  pliability,  in 
fact  feels  as  if  it  were  not  long  enough.  Never- 
theless sclerodermia  may  lead  to  arthritis. 

To  mistake  chronic  arthritis — osteoarthritis 
deformans — for  osteoarthropatMe  hypertrophi- 


JOINTS  505 

ante  pneumique  Marie,  seems  to  me  impossible. 
I  admit  that  the  diagnosis  may  offer  some  diffi- 
culty when  the  latter  affection  is  associated  with 
articular  troubles.  But  the  clinical  signs  char- 
acteristic of  the  disease  together  with  the  Roent- 
gen picture  ought  to  be  sufficient  criteria.  Still 
the  error  might  be  pardoned  in  the  incipient 
stages  of  osteorarthropathy  when  the  changes 
in  the  bones  have  just  barely  reached  the  car- 
tilage in  the  joint  caps  with  resultant  pains  and 
impaired  motility  in  the  joints. 

Under  "Pains  in  the  Bones"  I  have  already 
mentioned  how  an  arthritis  deformans  may  erro- 
neously be  diagnosed  in  senile  osteomalacia,  or 
osteoporosis. 

A  relatively  rapid,  subacute  arthritis  defor- 
mans with  well-defined  disfiguration  and  en- 
largement of  the  joint  may  be  readily  simulated 
by  a  primary,  malignant  neoplasm  in  the  bone 
or  by  an  epiphyseal  or  juxtaphyseal  sarcoma 
of  the  bone-marrow,  for  we  find  here  enormous 
swellings  in  the  articular  region,  the  articular 
outlines  disappear  almost  entirely  and  the  skin 
has  a  reddish,  or  rather  bluish  red  appearance 
and  is  feverish,  no  doubt  owing  to  venous  stasis. 
But  the  fact  that  the  motility  of  the  joint 
remains  unimpaired,  even  though  pain  (mostly 
slight)  does  exist,  and  the  evidence  of  deformi- 
ties in  the  bones,  of  ectatic  veins  in  the  skin  of 
the  affected  part,  together  with  the  X-ray  should 


506  GENERALIZED   PAIN 

be  the  guiding  points  in  the  diagnosis.  Only 
a  tub erculo- fungoid  or  perhaps  a  chronic  syphi- 
litic (pseudo-tumor  albus  lueticus)  articular 
affection  or  an  arihropaihy  might  become  a 
disturbing  element. 

The  differential  diagnosis  between  an  arthro- 
pathy  and  an  arthritis  deformans  may  always 
be  based  on  the  following  lines:  in  arthritis 
deformans  the  beginning  is  slow,  in  arthropathy 
the  attack  is  sudden  and  acute;  in  arthritis  de- 
formans the  articular  processes  are  impaired, 
impeded,  in  arthropathy  they  are  enlarged  (loose 
joints) ;  in  arthritis  deformans  the  disfiguration 
is  confined  to  the  joint,  in  arthropathy  it  extends 
beyond;  in  the  former  there  is  pain  in  the  joint, 
in  the  latter,  as  a  rule,  none. 

In  subacute  or  chronic,  mostly  exudative  mon- 
arthritis,  for  instance,  in  the  knee  joint,  we  must 
always  think  of  a  subacute  or  chronic  osteomye- 
litis as  the  provocative  cause.  This  is  generally 
located  in  the  part  of  the  bone  nearest  to  the 
joint  affected.  Articular  tuberculosis  or  articu- 
lar neuralgia  is  very  often  the  erroneous  diag- 
nosis in  these  cases.  The  seat  of  the  trouble  is 
centered  in  some  purulent  condition  in  the  lungs 
or  pleura.  Roentgenographic  evidence  will  as- 
sist the  diagnosis. 

When  we  hear  of  pains  in  the  knee  or  hip 
joints  we  should  not  only  think  of  local  affec- 
tions, among  them  genu  valgum,  varum,  flexum, 


JOINTS  507 

recurvatum,  but  we  must  likewise  give  attention 
to  reflex  pains  due  to  flat  foot. 

Coxitis  shows  pains  in  one  kneejoint,  a  sign 
of  importance  not  only  for  the  surgeon,  but  also 
for  the  internist  because  the  same  conditions  ap- 
ply in  osteoarthritis  deformans  of  the  hip  as 
they  do  in  coxitis.  The  examination  should  be 
based  on  the  proof  that  when  standing  up  the 
patient  cannot  properly  abduct  the  femur  in  its 
joint.  The  X-ray  will  show  the  existence  of 
an  arthritis  deformans  in  the  hip  joint  when 
the  knee  joint  is  normal. 

Sometimes  it  will  be  difficult  to  differentiate 
between  omarihritis  and  brackial  neuritis.  (Cf. 
chapter  "Pains  in  the  Shoulders.")  Here  it  is 
wise  to  make  a  thorough  examination  of  the 
legs,  especially  the  vascular  regions.  We  may 
find  then  whether  we  have  before  us  a  case  of 
arthritis  of  the  hip  joint  or  an  acute  osteomye- 
litis of  the  head  of  the  femur  or  of  the  iliac 
section,  or  an  arthritis  of  the  sacro-iliac  articu- 
lation or  a  rheumatism  of  the  gluteal  muscles. 
The  latter  will  be  recognized  by  the  presence 
of  pressure  points  (not  always  in  evidence), 
accentuated  pain  in  abdominal  exertion,  and  the 
sciatic  phenomenon.  If  we  find  that  the  sacro- 
iliac  region  is  especially  tender  to  pressure,  that 
a  quick  and  full  lateral  pressure  of  the  pelvis 
sharpens  the  pain,  we  are  dealing  with  arthritis 
of  the  articulation  belonging  to  that  region.  In 


508  GENERALIZED   PAIN 

arthritis  of  the  hip  joint  the  salient  features  are: 
deep  seated  pain,  throbbing  sensation  in  the 
major  trochanter,  the  impossibility  to  hyper- 
extend  the  hip  joint  to  twenty-five  or  thirty 
degrees  when  the  patient  is  lying  on  his  stomach 
— always  possible  in  normal  individuals,  but 
impossible  also  in  spondylitis  with  abscess  in  a 
dependent  part  as  well  as  in  all  forms  of  psoitis, 
likewise  in  retro  -  cecal  appendicitis,  impaired 
motility  in  the  sense  of  abduction,  especially  in 
the  standing  posture,  the  disappearance  of  pain 
when  lying  prone  (except  in  sciatica  when  pain 
is  always  present).  Much  may  be  learned  from 
the  Roentgen-ray  picture.  The  constancy  of 
the  pains,  leucocytosis  and  the  fact  that  even 
cautious  movement  in  the  hip  joint  is  not  pos- 
sible, speak  for  osteomyelitis  and  against  arti- 
cular affections.  In  rheumatism  of  the  gluteal 
muscles — a  rather  rare  disease — the  spontaneous 
and  pressure  pains  are  diffuse,  not  only  exacer- 
bated by  movements  of  the  lower  extremity,  but 
also  by  simple,  active  contraction  of  the  gluteal 
muscular  plexus  without  locomotion  of  the  ex- 
tremity. 


Headache  (Cephalea,  Cephalalgia) 

The  causes  of  headache  are  as  numerous  as 
the  complaints  thereof.  To  recognize  headache 
properly  and  make  a  fitting  etiologic  diagnosis 
— without  the  latter  there  is  no  efficient  therapy 
—we  must  always  be  alive  to  the  fact  that  this 
affection  is  primarily  located  within  or  without 
the  cranial  sphere,  but  that  the  originating  cause 
may  be  centered  in  a  local,  or  distant  part  of 
the  anatomy  or  may  be  quite  general  in  its 
nature. 

It  is  my  experience  that  those  headaches  which 
are  due  to  changes  in  the  cranial  shell  are  most 
frequently  overlooked,  because  an  important 
rule  which  I  earnestly  advise  my  readers  to  keep 
always  before  them,  is  so  often  overlooked,  viz., 
"In  complaints  of  headache  make  a  thorough 
inspection  and  palpation  of  the  cranium." 

If  you  observe  this  rule  carefully  you  will 
soon  learn  that  headaches  may  have  their  origin 
in  the  scalp.  Wounds,  sores,  inflammation, 
phlegmons  concern  the  surgeon.  To  the  inter- 
nist of  interest  is  erysipelas  of  the  scalp.  I  do 
not  mean  the  form  which  is  so  often  an  exten- 
sion of  facial  erysipelas,  but  that  affection  which 
originates  directly  in  the  scalp  itself  from  a 

609 


510  GENERALIZED   PAIN 

scratch  or  a  fissure  in  the  skin,  with  a  dragging, 
drawing  pain.  Only  a  very  painstaking  search 
for  such  a  scarcely  noticeable  lesion  will  lead  to 
a  happy  diagnosis.  Mark  the  localized  redden- 
ing of  the  skin  and  the  inflammatory  areola— 
neither  of  these  signs  ever  appear  so  distinctly 
marked  in  erysipelas  of  the  scalp  because  the 
skin  in  this  affection  is  drawn  too  tight — the 
localized  pressure  sensibility,  glandular  swellings 
and  the  symptoms  of  a  general  infection.  The 
diagnosis  is  beset  with  difficulty  in  individuals 
of  advanced  age  because  in  them  the  general 
manifestations,  especially  in  the  temperature  are 
no  longer  so  pronounced. 

That  form  of  headache  which  is  called  clavus 
hystericus,  (hysterical  hair  ache)  is  basic  in  a 
hyperesthesia  of  the  scalp.  The  patient  feels  a 
sensation  as  if  a  nail  were  being  driven  into  the 
head,  or  as  if  there  were  a  wound,  a  sore  on  the 
aching  spot.  Sometimes  the  pain  is  quite  diffuse, 
or  centered  in  the  very  vertex,  and  the  hair  is 
sensitive  to  touch.  When  a  woman  pulls  the  hair 
upwards  in  combing  there  is  pain  in  the  scalp 
similar  to  toothache,  especially  on  the  top  of  the 
head. 

Painful  sensitiveness  on  pressure  is  a  promi- 
nent symptom  of  neuralgic  headache.  But  here 
the  pain  is  confined  to  the  zone  in  which  the 
affected  nerves  are  located.  It  generally  follows 
two  distinct  lines,  either  along  the  trigeminus  or 


HEAD  511 

the  nervus  occipitalis,  both  major  and  minor. 
In  consequence  the  local  sensitiveness  to  pres- 
sure pain  in  supraorbital  neuralgia  corresponds 
with  the  supraorbital  nerve  process  from  the 
supraorbital  foramen,  in  neuralgia  of  the  nervus 
occipitalis  to  about  the  middle  of  a  connecting 
line  between  the  mastoid  and  spinous  process. 

In  both  a  proper  etiologic  distinction  between 
genuine  and  deuteropathic  neuralgia  must  be 
made.  If  the  latter  is  the  case  and  supraorbital 
neuralgia  is  present,  we  must  direct  our  mind 
to  affections  of  the  osseous  surroundings  of  the 
n.  supraorbitalis,  to  arteriosclerosis  of  the  vasa 
vasorum  of  the  nerves,  diseases  of  the  oral  cavi- 
ties, the  eye,  the  nose  and  its  cavities,  the  ear, 
the  brain  (tumors  of  any  kind,  also  tuberculosis, 
gummata,  multiple  sclerosis,  etc.),  all  of  which 
are  causative  elements,  especially  preceding  in- 
fectious diseases,  principally  malaria  and  syphilis, 
existing  metabolic  disturbances  (gout,  diabetes 
mellitus),  colds  and  constipation. 

In  cervico-occipital  neuralgia  similar  condi- 
tions prevail,  but  in  addition  we  should  look 
for  affections  of  the  cervical  vertebrae,  especially 
the  first  and  second,  also  the  spinal  cord,  but 
particularly  for  syphilitic  cervical  hypertrophic 
pachymeningitis  in  which  pains  also  occur  in  the 
arms,  and,  in  exceptional  cases,  for  pains  in  the 
occiput.  Neither  must  we  forget  localized  affec- 
tions in  the  posterior  section  of  the  head  (cere- 


512  GENERALIZED   PAIN 

bellum,  medulla  oblongata),  radiations  of  pain 
along  the  neck  into  the  shoulders  and  arms, 
diseases  of  the  sphenoid  sinus  and  all  possible 
affections  in  the  retromediastinal  space  (see 
chapter  on  "Pains  in  the  Neck").  Only  a  care- 
ful scrutiny  of  all  these  conditions  can  assure 
us  of  a  correct  diagnosis. 

If  a  patient  complains  of  intense  pains  in  the 
head  which  come  on  in  sudden  periodical  attacks, 
last  sometimes  for  two  or  three  weeks  on  a 
stretch  and  are  of  a  neuralgiform,  shooting  and 
piercing  character,  we  should  promptly  suspect 
a  case  of  lancinating  pains  in  tabes  cerebralis. 
Beyond  the  customary  symptoms  we  may  expect 
no  nervous  sensitiveness  to  pressure  pain,  no 
nervous  pressure  points,  but  rather  objective 
sensibility  disturbances  in  the  sense  of  hypo-  or 
anesthesia,  resp.  analgesia. 

Headache  of  a  neuralgic  character  may  be  a 
manifestation  of  a  local  lesion  in  any  part  of 
the  trigeminal  plexus  or  of  any  other  encroach- 
ment in  the  frontal  region.  Circumscribed, 
chronic,  local  meningitides,  basilar  cranial  and 
cerebral  tumors  and  those  of  the  angle  of  the 
cerebellar  pons  will  surely  give  rise  to  neuralgi- 
form headaches.  The  diagnosis  results  from 
the  local  and  general  symptoms. 

Myalgia  capitis  is  rheumatism  of  the  scalp 
and  the  cause  of  acute,  continuous,  exacerbated 
attacks  of  headache.  The  diagnosis  is  guided 


HEAD  513 

by  the  presence  of  hard,  painful,  lumpy  indura- 
tions along  the  linea  semicircularis  where  the 
muscles  are  attached  to  the  cranium,  especially 
the  splenicus  and  m.  cucullaris,  also  the  sterno- 
cleidomastoid  and  scalenus.  Very  sensitive  no- 
dules in  the  panniculus  cavernosus  of  the  occiput 
and  of  the  nape  of  the  neck  may  also  be  felt. 
There  is  pressure  pain  in  the  periostea  of  the 
superior  vertebrae,  especially  in  the  transverse 
processes. 

The  patient  complains  of  a  tearing  pain  in 
the  head,  exacerbated  when  chewing  or  speaking 
(also  a  symptom  in  neuralgia  of  the  trigeminus), 
or  by  the  pressure  of  a  hard  hat,  or  by  combing 
the  hair.  The  pain  is  sometimes  relieved  by  a 
brisk  movement  of  the  head,  but  it  may  be  also 
aggrevated  by  it. 

In  bald-headed  people  myalgia  capitis  is  not 
uncommon,  likewise  in  women  who  contract  a 
cold  from  washing  the  hair,  or  when  the  hair 
gets  wet  through  some  accidental  cause,  going 
from  a  warm  room  into  a  colder  atmosphere,  or 
exposure  to  drafts  or  cold  winds.  The  pain 
prevails  chiefly  in  the  back  part  of  the  head, 
rarely  in  the  temples  or  forehead.  A  dose  of  a 
salicylic  preparation,  massage  and  wet  bandages 
frequently  bring  relief. 

The  crural  part  of  the  cranium  may  be  a 
source  of  headache.  I  mention  here  syphilis  of 
the  bones  or  of  the  periosteum.  When  osten- 


514  GENERALIZED   PAIN 

sible  gummata  exist,  the  diagnosis  offers  no  diffi- 
culties. But  when  these  are  not  in  evidence,  we 
should  look  for  the  nocturnal  appearance  or 
aggravation  of  the  pains  especially  before  or 
around  the  midnight  hour — always  a  strong  hint 
for  the  syphilitic  genesis  of  the  aches  (but  not 
pathognomonic) . 

Such  headaches  with  nocturnal  habits  are  also 
found  in  tumors  of  the  brain,  especially  in  aneu- 
rysms  of  the  vertebral  and  basilar  arteries,  in 
uremia,  arterial  hypertension,  dental  affections 
(caries),  glaucoma,  and  also  in  diabetes,  hysteria 
and  migraine,  not  to  speak  of  patients  who  work 
in  the  night  time.  Their  nocturnal  character 
together  with  the  complementary  corrective  re- 
action and  the  results  obtained  from  therapeutic 
measures  should  easily  put  upon  them  the  stamp 
of  dolores  osteocopi  luetici. 

Osteocopic  pains  mature  also  in  other  morbid 
conditions  of  the  osseous  portion  of  the  cranium, 
viz.,  hyperostosis  (leontiasis  ossea),  in  neoplasms 
(chloroma,  carcinoma,  sarcoma),  myeloma,  fam- 
ine osteopathy  (sensation  of  hammering  in  the 
skull).  The  pains  are  generally  in  the  shape  of 
attacks  of  an  intermittent  character,  while  in 
some  cases  they  do  not  appear  at  all.  Caries  of 
the  cranial  bones  and  cold  abscess  also  belong 
here. 

Pyrgocephalus  is  only  mentioned  here  casu- 
ally. Fuller  details  will  be  given  later  on,  be- 


515 

cause  the  pains  in  it  are  more  in  the  form  of 
migraine.  , 

That  in  traumatic  periostitis  headaches  prevail 
is  self-evident,  for  in  it  impressions  of  the  os- 
seous cranium  can  be  easily  demonstrated  by 
radiology.  The  cause  of  headache  in  cranial 
trauma  is  frequently  focused  in  intracranial 
conditions.  In  some  cases  these  pains  pass  away 
quickly  and  may  be  attributed  to  a  transient 
minor  circulatory  disturbance  or  to  some  cellular 
encapsulation.  In  other  cases  the  root  of  the 
evil  may  be  traced  to  cerebral  commotion,  com- 
pression or  contusion  or  to  some  hematoma  of 
the  dura  or  a  traumatic  rupture  of  the  median 
meningeal  artery,  an  intermeningeal  hemorrhage 
or  an  abscess  in  the  brain  or  a  traumatic  neu- 
rosis. The  diagnosis  is  irrelevant  in  this  place. 

What  is  of  interest  to  the  internist  is  the  fact 
that  headaches  with  giddiness — especially  when 
stooping  down — nausea,  abnormal  irritability  or 
fainting,  also  loss  of  consciousness  and  intoler- 
ance for  alcohol  are  the  inevitable  after-effects 
of  a  previous  concussion  of  the  brain.  This 
knowledge  would  forestall  an  erroneous  diagnosis 
of  "simple"  traumatic  neurosis  in  many  cases. 
Headache  with  increasing  lumbar  pressure  indi- 
cates very  often  chronic  serous  posttyaumatic 
meningitis,  even  if  only  as  a  localized  condition. 
An  important  symptom  in  all  these  cranial  af- 
fections is  a  persistent  hypersensitive  pressure 


516  GENERALIZED   PAIN 

zone  endowed  with  the  sensation  of  a  hot  sponge 
wiping  over  it. 

We  now  pass  over  to  that  chain  of  inter- 
cranial  affections  without  trauma  which  may  be 
the  source  of  headaches.  With  the  exception  of 
cerebral  atrophy  all  other  diseases  that  occur  in 
the  cranial  cavity,  of  whatever  nature,  are  here 
included.  We  shall  only  deal  now  with  those 
endocranial  headaches  that  are  determining  diag- 
nostic factors. 

The  diagnosis  of  chronic  periostitis  can  be 
made  absolute  by  the  X-rays,  unless  there  are 
external  perceptible  signs  of  osseous  changes  or 
some  definite  symptoms  of  a  cerebromeningeal 
lesion.  The  same  may  be  said  of  intracranial 
osteoperiostitis.  In  fact  it  is  the  only  means  at 
our  command  whereby  we  may  obtain  undoubted 
results,  for  a  differential  diagnosis  between 
syphilitic  ostitis,  between  the  dura  and  the  roof 
of  the  cranium  on  the  one  hand,  and  pachy-  or 
gummatous  leptomeningitis  on  the  other  can 
hardly  be  established. 

The  diagnosis  of  internal  hemorrhagic  pachy- 
meningitis  is  beset  with  many  difficulties.  It 
occurs  in  marantic  individuals,  in  nephrosclerosis, 
in  heavy  drinkers  and  in  old  people.  Apart  from 
the  conditions  mentioned  above  we  find  the  fol- 
lowing: the  patient  complains  of  headache,  peri- 
odical vomiting,  befogged  consciousness,  paretic 
conditions  of  certain  cerebral  nerves,  pupillary 


HEAD  517 

differences  and  disturbances  in  speech.  The 
body  temperature  remains  unchanged.  Impor- 
tant for  the  diagnosis,  especially  for  the  differen- 
tiation from  an  intracerebral  affection  is  the  fact 
that  there  is  a  marked  contrast  between  the  cere- 
bral paresis  or  paralysis  of  the  extremities  and 
that  of  the  respiratory  muscles  of  the  thorax, 
and  that  the  patient  breathes  with  more  ease  on 
the  affected  side. 

Of  course,  this  does  not  establish  a  differentia- 
tion from  a  convexity  leptomeningitis  which  runs 
a  course  similar  to  pachymeningitis.  But  wor- 
thy of  note  is  that  internal  hemorrhagic  pachy- 
meningitis has  a  partiality  for  clinically  one-sided 
external,  irritating  symptoms,  whilst  in  the  other 
forms  of  convexity  meningitis  these  manifesta- 
tions bear  a  much  more  generalized  character. 
Hemorrhages  do  not  always  occur  in  any  of 
these  varieties,  especially  not  in  the  earlier  stages 
of  the  diseases.  Then  there  is  the  diffuse  form 
with  a  limited  partial  symptom  complex,  basic 
in  a  stronger,  unilateral  meningeal  progression 
or  also  in  a  partial  encephalitis  or  vascular  lesion 
( thromboarthritis ) . 

Still  more  distressing  are  the  cephalic  pains  in 
all  forms  of  leptomeningitis.  The  accession  of 
throbbing  pains  is  a  telling  symptom. 

Cephalalgia  is  a  frequent  initial  symptom  in 
acute  (epidemic)  encephalitis  and  one  of  its 
after-effects. 


518  GENERALIZED    PAIN 

In  multiple  sclerosis  the  pains  come  in  recur- 
rent attacks,  now  from  a  frontal,  now  from  a 
vertical,  or  again  from  an  occipital  direction. 
At  times  they  are  of  a  very  intensive  character 
and  accompanied  by  vomiting  and  giddiness. 

The  acme  of  pain  in  the  head  is  reached  in 
three  other  intracranial  morbid  processes,  viz., 
in  tumor  of  the  brain  (including  cysticercus  and 
pseudotumors),  in  chronic  abscess  of  the  brain 
and  in  chronic  serous  meningitis.  When  the 
intracranial  pressure,  which  is  generally  asso- 
ciated in  a  violent  form  with  these  ailments,  is, 
however,  of  a  more  moderate  character,  the  pains 
will  also  be  lighter  in  proportion.  This  puts  the 
stamp  of  a  weighty  symptom  on  the  initial  head- 
aches in  acromegaly.  It  assumes  here  mostly 
the  form  of  a  dull  pain  in  the  frontal  region, 
perhaps  only  on  one  side,  whilst  in  other  hypo- 
physeal  diseases  the  occipital  portion  is  rather 
involved. 

Cerebral  vomiting  frequently  occurs  in  all 
these  affections  and  is  a  stereotyped  signal  for 
the  diagnosis.  The  pain  is  aggravated  by  other 
accompanying  symptoms  such  as  muscular  exer- 
tion in  coughing,  sneezing,  defecation  or  stoop- 
ing down,  all  of  which  tend  to  increased  pressure 
on  the  cranium  from  within.  Another  source  of 
irritation  is  the  intake  of  alcoholic  stimulants. 
In  chronic  serous  meningitis  the  pain  is  more 
diffused,  whilst  in  cerebral  tumors  it  either 


HEAD  519 

spreads  over  the  entire  cranium,  or  at  any  rate, 
if  localized,  is  more  intensely  punctuated  in  a 
certain  spot,  in  which  case,  however,  it  must  not 
be  accepted  as  an  indication  of  the  real  seat  of 
the  tumor.  Even  a  neuralgiform  pain  in  the 
trigeminal  zone  is  not  an  unconditional  local 
symptom.  In  cerebral  abscess  the  site  of  the 
pain  corresponds  with  the  local  suppuration 
thus  pointing  out  the  seat  of  the  disease,  but  not 
invariably.  In  both,  tumor  as  well  as  abscess  of 
the  brain,  the  pains  are  nearly  always  of  the 
deepest  intensity  when  located  in  the  posterior 
portion  of  the  cranial  cavity  they  encroach  on 
the  circulation  of  the  vena  magna  Galeni  and 
in  the  aqueduct  of  Silvius.  Magendie's  foramen 
being  occluded  a  similar  effect  results  in  men- 
ingitis. 

The  impairment  of  the  venous  circulation, 
often  of  diagnostic  significance,  in  tumors  of 
the  brain,  only  partially  explains  why  the  pains 
are  aggravated  when  the  head  is  held  in  a  certain 
position.  This  is  particularly  so  in  cerebellar 
tumors.  When  the  patient  rests  the  head  on  the 
affected  side  the  pains  set  in,  at  least  in  the 
beginning  of  the  sickness.  This  is  also  the  case 
in  cysticercus  of  the  fourth  ventricle.  The  pa- 
tient gives  his  head  a  forced  position,  sometimes 
to  the  right  or  left,  sometimes  forward  or  back- 
ward, in  order  to  make  the  pain  more  tolerable. 
The  same  happens  also  in  renal  headaches. 


520  GENERALIZED   PAIN 

When,  however,  an  occipital  pain  is  very  much 
exaggerated  by  a  forward  inclination  of  the 
head,  when  the  patient  has  the  sensation  as  if 
the  skull  would  burst,  we  must  look  for  another 
cause.  We  should  be  prepared  to  find  a  com- 
pression of  the  aqueduct  of  Silvius  or  an  acute 
hydrocephalus  of  the  fourth  ventricle. 

A  point  of  value  for  the  diagnostician  is  the 
observation  that  in  some  rare  cases  the  pains 
are  of  a  strongly  remittent  even  intermittent 
character.  An  erroneous  diagnosis  of  neurosis 
is  here  not  excluded. 

There  are  many  cases  of  this  kind  which  are 
very  difficult  to  diagnose.  We  should  never  be 
rash  in  diagnosing  neurosis  from  remittent  or 
intermittent  violent  attacks  of  headache  persist- 
ing for  days  or  weeks,  but  rather  direct  our 
thoughts  to  serous  meningitis  or  brain  tumor 
or  cerebral  chronic  abscess,  even  when  the  ail- 
ment drags  through  several  years.  The  same 
idea  should  be  followed  when  an  undoubted 
trauma  has  preceded  the  apparently  "neurotic" 
symptom  complex.  Every  practitioner  with 
some  clinical  experience  has  seen  cases  in  which 
chronic  serous  meningitis  followed  on  the  heels 
of  some  cranial  traumatic  affection  running  its 
course  exclusively  under  neurasthenic  conditions 
such  as  persistent  or  else  periodic  headache,  back- 
ache, giddiness,  abnormal  irritability  and  psychic 
emotions.  And  does  that  not  happen  also  in 


HEAD  521 

chronic  post-traumatic  abscess  of  the  brain? 
Even  light,  continued  headaches  may  constitute 
the  solitary  symptom  of  a  hitherto  latent  cere- 
bral abscess. 

There  are  other  forms  of  periodic  headaches 
which  build  up  from  ascending  intracranial  pres- 
sure. More  about  this  when  we  are  dealing  with 
infectious  diseases.  In  passing  I  will  only  men- 
tion here  that  in  an  analogous  manner  certain 
cephalalgic  attacks  in  chronic  alcoholism  may 
be  explained,  especially  when  they  are  associated 
with  tinnitus,  stupor,  nystagmus,  amblyopia 
without  ophthalmic  conditions  at  times  aggra- 
vated by  coughing  or  sneezing.  They  yield,  as 
a  rule,  to  lumbar  puncture.  The  etiologic  diag- 
nosis is  made  positive  when  tremor  of  the  hands 
and  tongue,  sleeplessness  and  morning  sickness 
present  themselves. 

Headache  in  hysteria  or  neurasthenia  cannot 
be  accepted  as  a  pathognomonic  manifestation 
per  se.  In  the  majority  of  these  cases  the  pain 
is  nothing  more  than  an  indefinite  cephalic  pres- 
sure covering  either  the  whole  circumference  or 
only  portions  of  the  skull  (forehead,  temples  or 
occiput),  although  in  neurasthenia  some  patients 
complain  of  external  constraint  such  as  might 
be  caused  by  a  hard  hat,  or  a  vice  or  a  circular 
band,  while  in  hysteria  the  feeling  is  more  as 
if  the  head  would  burst  from  within;  there  is 
also  hyperesthesia  of  the  scalp  and  hairache. 


522  GENERALIZED   PAIN 

Hysterical  headaches  may  also  assume  the  form 
of  clavus — a  sign  which  is  unknown  in  neuras- 
thenia— aroused  sometimes  by  the  rays  of  a 
glaring  light  or  some  loud  noise. 

But  there  are  cases  of  hysteria  in  which  the 
headache  simulates  the  character  of  a  neuralgia 
by  running  along  the  nerves  of  the  cranial  roof 
into  those  of  the  occiput  and  branching  out  even 
as  far  as  the  nape  of  the  neck  or  else  into  the 
frontal  section  and  the  face  itself.  The  differen- 
tial diagnosis  may  be  drawn  from  the  fact  that 
the  headache  is  not  confined  to  the  path  of  the 
nerves  but  radiates  into  adjacent  ground,  that 
the  head  feels  as  if  ready  to  burst  in  two  from 
within  and  that  classical  pressure  points  are 
missing — all  characteristic  symptoms  of  hysteri- 
cal and  non-neuralgic  conditions. 

Neurasthenic  headache  sometimes  attended 
with  slight  excitability  or  weariness  or  wakeful- 
ness  is  not  uncommonly  the  sole  symptom  of 
neurasthenia.  But  there  are  other  signs  which 
may  help  in  the  diagnosis,  viz.,  mental  overex- 
ertion,  psychic  or  sexual  hyperexcitement,  late 
hours,  and  changeable  weather  conditions,  more 
acute  in  the  early  hours  of  the  day;  also  the  fact 
that  unlike  constitutional  forms  of  headache,  e.g., 
migraine  or  brain  tumors,  it  is  improved  by  or 
disappears  altogether  with  open  air  exercise  or 
walking  or  riding  bareheaded. 

Hysteroneurasthenia  should  not  be  overlooked 


HEAD  523 

in  this  connection.  Arteriosclerosis  of  the  cere- 
bral vessels  presents  not  only  headache  but  also 
other  cerebral  symptoms  which  are  analogous 
to  neurasthenia.  The  headache  is  chiefly  local- 
ized in  the  frontal  region  and  is  of  a  piercing, 
boring,  shooting,  dull  character,  accompanied  by 
giddiness,  loss  of  memory,  sleeplessness,  irri- 
tability and  fatigue.  In  all  these  qualities  it 
strongly  resembles  neurasthenia,  a  circumstance 
that  makes  the  diagnosis  difficult.  The  minor 
symptoms  such  as  dizziness,  paresthesia  of  the 
extremities,  inhibition  of  speech,  changes  in  the 
handwriting,  vivaciousness,  relate  rather  to  arte- 
riosclerosis, although  they  are  not  foreign  to 
neurasthenia.  Arteriosclerotic  headache  may 
easily  be  caused  by  a  physical  strain  in  cough- 
ing, sneezing  or  during  defecation,  that  is  to  say 
by  every  form  of  increased  blood  pressure,  while 
on  the  other  hand  this  does  not  seem  to  be  the 
case  in  neurasthenia. 

Other  distinguishing  signs  are:  it  mostly  comes 
on  in  the  early  morning  hours,  starting  the  pa- 
tient out  of  his  sleep,  like  a  thunderbolt,  some- 
times it  bears  the  character  of  migraine.  In  spite 
of  all  this,  I  mean  to  say  that  the  determining 
factor  will  always  be  found  in  the  etiology  of 
the  case,  especially  in  face  of  the  fact  that  the 
presence  or  absence  of  peripheral  arteriosclerosis 
does  neither  prove  nor  gainsay  the  existence  of 
a  sclerosis  in  the  cerebral  vssels.  If  we  fail  to 


524  GENERALIZED   PAIN 

discover  the  causative  force  of  the  apparently 
neurasthenic  conditions  (mental  overstrain,  psy- 
chic emotions),  and  if  the  patient  is  advanced 
in  years  (beyond  the  fifties),  I  should  be  in 
favor  of  diagnosing  pseudoneurasthenia  basic  in 
arteriosclerosis  resp.  pseudoneurasthenic  head- 
ache. Nevertheless,  arteriosclerosis  has  been 
observed  in  younger  persons,  especially  after 
some  preceding  infectious  disease  such  as  syphi- 
lis, malaria  and  toxic  conditions  (lead  poison- 
ing). Neither  must  we  overlook  the  fact  that 
a  genuine  attack  of  neurasthenia  may  spring 
from  a  preexisting  demonstrable  arteriosclerosis 
of  the  afferent  vessels.  Still  the  diagnosis  of 
such  a  combination  would  not  be  justified  unless 
there  is  unmistakable  proof  of  the  provocative 
cause. 

If  the  patient  begins  to  complain  of  headache 
we  must  consider  the  likelihood  of  an  additional 
cerebral  complication  such  as  thrombosis  of  the 
cerebral  arteries  or  cerebral  hemorrhage.  Either 
of  these  may  occur  in  older  persons  with  a  con- 
tracted kidney,  and  in  younger  individuals  with 
arterial  calcification.  Such  headaches  are,  more- 
over, a  valuable  symptom  for  the  differential 
diagnosis  between  thrombotic  softening  of  the 
brain  and  cerebral  hemorrhage.  If  the  pains 
have  prevailed  for  hours  or  days  before  the 
attack  of  cerebral  hemiplegia  set  in,  they  point 
to  thrombotic  softening  of  the  brain.  In  arterio- 


HEAD  525 

sclerosis  the  headache  does  not  always  bear  the 
neurasthenic  character  but  rather  assumes  that 
of  a  boring,  shooting  or  stitching  sensation,  espe- 
cially after  psychic  emotions. 

Similar  manifestations  are  observed  in  the 
incipient  stages  of  syphilitic  endarteritis  of  the 
brain;  likewise  in  progressive  paralysis,  the 
earlier  epochs  of  organic  tuberculosis — chiefly 
pulmonary  —  in  Addison's  disease,  contracted 
kidney  or  in  some  of  the  toxic  affections.  The 
pains  may  mimic  neurasthenia  and  thus  create 
a  pseudoneurasthenic  symptom  complex. 

Sclerosis  of  the  cerebral  arteries  frequently 
opens  the  road  to  the  formation  of  aneurysms, 
especially  in  the  sphere  of  the  basal  vessels.  The 
evidence  of  combined  general  pressure  and  local 
compression  symptoms  (e.g.,  in  aneurysm  of 
the  vertebral  or  basilar  artery  of  bulbar  symp- 
toms) is  of  great  value  for  the  diagnosis.  If 
blood  or  clods  are  found  in  the  fluid  obtained  by 
lumbar  puncture  the  diagnosis  is  absolute. 

Dementia  precox,  progressive  paralysis  and 
other  mental  affections  are  capable  of  creating 
a  "pseudoneurasthenic"  symptom  complex  with 
distressing  headaches.  It  is  often  clinically  diffi- 
cult to  distinguish  between  neurasthenia  and  an 
early  progressive  paralysis.  The  character  of 
the  headache  may  here  be  a  determining  factor. 
In  neurasthenia  the  pain  is  rather  in  the  form 
of  pressure,  although  psychic  emotions  or  fatigue 


526  GENERALIZED   PAIN 

may  give  it  the  nature  of  a  real  ache;  it  is 
sharper  in  the  morning,  tapers  down  as  the  hours 
pass  by  and  vanishes  with  the  setting  sun;  it 
obsesses  the  patient  with  the  fear  of  "going 
mad." 

In  paralysis  the  pressure  in  the  head  is  not 
so  predominant,  but  we  find  rather  a  progres- 
sive weakening  of  memory  and  striking  changes 
in  the  personality  of  the  patient.  And  yet, 
progressive  paralysis  may  wear  the  mask  of  a 
cerebral  asthenia  and  may  be  accompanied  by 
sleeplessness  and  very  severe  pains  in  the  head. 
But  etiology  and  the  somatic  symptoms  should 
here  help  us  out,  viz.,  change  in  the  pupils,  the 
missing  light  and  pain  reaction,  weakening  of 
the  patellar  reflexes,  trembling  of  the  lips,  an- 
omalies of  speech,  change  in  the  hand-writing, 
not  to  forget  lumbar  puncture.  Nonne-Appelt, 
Wassermann,  plyocytosis,  all  positive.  Never- 
theless a  positive  Wassermann  reaction  should 
be  accepted  with  caution,  for  syphilitic  patients 
are  frequently  neurasthenic. 

In  dementia  precox  there  is  more  pressure,  a 
fullness  of  the  head,  than  direct  pain.  Abnormal 
fatigue,  impaired  capacity  for  work,  noticeable 
deterioration  of  the  mental  faculties,  are  im- 
portant points  to  watch.  The  anomalous  hyper- 
excitability  of  the  neurasthenic  is  lacking.  While 
in  neurasthenia  nervosity  runs  parallel  with 
external  stimulation,  the  nervous  spells  in  de- 


HEAD  527 

mentia  precox  come  on  like  explosions  to  make 
room  immediately  after  for  dull  inactivity. 

Of  course,  all  melancholic  and  depressing 
psychoses  carry  parasitic  headaches. 

Anemia,  no  matter  what  its  genesis  may  be, 
and  hyperemia  of  the  brain  arouse  pains  in  the 
head.  In  anemia  the  pains  are  not  often  of  a 
very  intensive  character,  but  may  appear  in 
different  localities,  and  in  company  with  other 
manifestations  such  as  vertigo,  fainting  fits, 
tinnitus  aurium,  nausea,  especially  when  the 
patient  suddenly  sits  up.  They  are  aggravated 
when  the  head  is  held  erect  or  when  the  abdom- 
inal muscles  undergo  a  strain,  but  soften  down 
with  a  horizontal  position  or  deep  inclination  of 
the  head.  In  anemic  women  this  headache  is  a 
steady  visitor  during  the  catamenial  period. 
This  is  important  for  the  reason  that  such  a 
pain,  localized  as  it  is  in  the  occipital  region  and 
associated  with  the  other  symptoms  already  enu- 
merated, may  very  well  point  to  some  internal 
hemorrhage. 

If  we  find,  however,  very  severe  headaches  in 
the  anemic  patient  we  should  at  once  suspect 
higher  pressure  in  the  cerebrospinal  fluid,  or 
some  complication  such  as  thrombosis  of  the 
cerebral  sinus  especially  when  other  symptoms, 
impaired  consciousness,  fainting  fits,  accede. 

A  special  form  of  cerebral  anemia  with  head- 
ache is  caused  by  insufficiency  of  the  aorta.  The 


528  GENERALIZED   PAIN 

quick  pulse  of  the  cerebral  arteries,  the  in-  and 
outflow  of  the  cerebral  blood  produce  the  sensa- 
tion of  pressure  simulating  neurasthenic  pains 
in  the  head  which  are  of  a  throbbing  and  very 
distressing  character,  very  much  in  the  nature 
of  similar  throbbing  epigastralgias  in  failure  of 
the  cardiac  valves.  Since  the  patients  afflicted 
with  the  latter  diseases  are  likewise  abnormally 
excitable  and  suffer  from  sleeplessness,  we  have 
again  a  pseudoneurasthenic  symptomatic  picture 
before  us. 

Anemia  of  the  brain  need  not  necessarily  be 
a  partial  manifestation  of  a  general  anemia,  nor 
the  result  of  defective  organic  circulation,  but 
may  result  from  local  vesicular  changes.  A 
considerable  contraction  of  the  os  art.  anonymce 
or  of  the  carotis  sin.  either  due  to  sclerosis  of 
the  aorta,  syphilitic  arteritis  or  complete  throm- 
bosis of  these  arteries,  will  surely  lead  to  anemic 
headache  with  vertigo. 

Hyperemia  of  the  brain  is  another  source  of 
headache,  but  only  in  those  cases  in  which  there 
is  polycyihemia  rubra.  The  patients  complain 
of  pressure  and  fullness  in  the  head,  the  pains 
are  sometimes  very  severe,  sometimes  migraine- 
like,  or  of  a  throbbing  character,  often  there 
are  congestions  combined  with  scintilating  sco- 
toma,  tinnitus  aurium,  giddiness,  sleeplessness, 
abnormal  excitability,  in  other  words  all  the 
"pseudoneurasthenic"  symptoms  again  as  men- 


HEAD  529 

tioned  before.  Blood  test  and  a  proper  clinical 
examination  should  make  the  diagnosis  clear. 

The  situation  is  very  much  the  same  when 
there  have  been  reiterated  ruptures  of  bloodves- 
sels followed  by  pain  and  dullness  in  the  head 
and  clumsiness  in  the  performance  of  the  daily 
tasks.  We  find  it  frequently  in  patients  suffer- 
ing from  hemorrhoids.  A  good  hemorrhage 
from  the  piles  gives  relief  all  around  and  clears 
the  head  of  painful  conditions. 

Passive  hyperemia  of  the  skull  can  only  then 
be  considered  a  cause  for  giddy  headache  when 
it  is  of  a  chronic  character.  The  pain  as  a  rule 
is  light,  but  may  become  bothersome  when  it 
spreads  over  a  larger  area  which  is  really  the 
case  in  venous  hyperemia  owing  to  insufficiency 
of  the  right  ventricle.  In  other  words  we  are 
dealing  here  with  a  high  grade  cardial  congestive 
cyanosis  of  the  brain,  mainly  by  relative  insuffi- 
ciency of  the  tricuspid  valve  and  by  direct 
restriction  in  the  circulation  of  the  vena  cava 
superior,  no  matter  whether  this  restriction  is 
caused  by  pressure  from  a  mediastinal  tumor  or 
a  chronic  mediastinitis  or  a  thrombosis  of  the 
vein  or  of  the  right  vestibule.  The  remaining 
symptoms  of  the  congestion  of  the  vena  cava 
sup.  (see  Cyanosis  and  Edema),  the  direct 
mediastinal  manifestations,  the  Oliver-Cardarelli 
symptom  and  the  Roentgen-ray  should  suffice 
to  trace  the  real  cause  of  the  headache. 


530  GENERALIZED    PAIN 

It  is  not  hard  to  understand  how  a  steadily 
rising  pressure  in  the  brain,  i.e.,  increased  venous 
stasis  (abdominal  pressure,  coughing,  inclining 
the  head  forward,  or  stooping,  etc.)  aggravates 
the  pain  sometimes  to  a  point  where  the  patient 
feels  as  if  the  head  would  split.  We  can  observe 
this  in  every  cerebral  cephalalgia,  in  arterioscle- 
rosis in  chronic  alcoholism,  in  vasomotoric  affec- 
tions, in  cerebral  arteriosclerosis,  in  affections  of 
the  nasal  cavities,  pressure  in  the  cerebrospinal 
fluid  or  in  the  arteries  or  in  cerebral  hyperemia. 
In  conditions  due  to  visual  refraction  these  pains 
do  not  seem  to  occur. 

Men  who  wear  high  collars,  too  narrow  around 
the  neck,  and  women  who  lace  too  tightly  are 
likely  to  suffer  from  headaches  owing  to  re- 
stricted venous  circulation. 

In  acute  venous  cerebral  congestion  headaches 
do  not,  as  a  rule,  play  a  prominent  part.  The 
complaint  is  more  of  pressure  and  dullness  than 
a  veritable  pain. 

But  in  phlebitis  and  thrombosis  of  any  parti- 
cular cerebral  sinus  severe  headaches  are  symp- 
tomatic, for  here  we  are  confronted  in  nearly 
all  cases  by  pseudomeningitic  conditions.  The 
diagnosis  is  greatly  assisted  when  we  find  a 
collateral  edema  on  the  outside  of  the  skull — 
in  thrombosis  of  the  longitudinal  sinus  a  swelling 
of  the  veins  at  the  roof  of  the  skull,  in  throm- 
bosis of  the  cavernous  sinus  an  edema  of  the 


HEAD  531 

! 
eyelids,  in  thrombosis  of  the  sigmoid  sinus  an 

edema  of  the  mastoid  process — and  when  we 
give  due  consideration  to  the  appurtenant  eti- 
ologic  factors  (nasal  and  aural  and  accessory 
cavities,  erysipelas  of  the  scalp,  marantic,  anemic 
thrombosis ) . 

Periodic  fluctuations  in  the  blood  stream  give 
rise  to  vasomotoric  headache.  In  the  vasopara- 
lytic  form  it  assumes  the  nature  of  rushes  to  the 
head  caused  by  certain  acute  intoxications,  alco- 
hol, chloroform,  nitrites,  especially  amyl  nitrite, 
and  chronic  theism.  Furthermore  there  are  other 
morbid  conditions  in  which  vasomotoric  changes 
are  liable  to  occur,  viz.,  neurosis  in  both  sexes, 
especially  the  climacteric  form  in  woman,  neu- 
rathenia,  hysteria,  traumatic  neurosis,  Base- 
dow's  disease,  chlorosis,  etc.  The  pain  in  these 
cases  generally  concentrates  in  the  region  of 
the  vertex  and  is  accompanied  by  various  vaso- 
motoric manifestations  (erythema,  dermograph- 
ism,  red  streaks  where  the  garments  pinch  the 
skin,  changes  in  the  complexion),  cold  hands 
and  feet,  chilliness,  heat,  inclement  weather  con- 
ditions. The  vasomotoric  hyperirritability  of  the 
skin  accompanying  these  headaches  is  also  pecu- 
liar to  serous  meningitis. 

The  climacteric  headache  is  generally  local- 
ized in  the  occipital  area.  Its  true  signs  are 
easily  recognized:  its  seasonable  advent  (some- 
times months  or  years  before  the  cessation  of 


532  GENERALIZED  PAIN 

the  menses  sets  in),  congestion,  rush  of  blood  to 
the  face  and  head,  unprovoked  breaking  out  of 
profuse  perspiration,  irritability,  anxiety,  worry 
and  general  depression.  Quasi  climacteric  neu- 
roses may  also  occur  in  the  male. 

There  is  also  a  vasoconstrictor  headache  of  an 
acute  (mainly  pressure  in  the  head)  as  well  as 
chronic  character,  e.g.,  nicotinism.  No  doubt, 
some  of  the  passing  symptoms  of  cerebral  arte- 
riosclerosis may  very  well  be  reduced  to  some 
vasoconstriction.  We  all  know  that  in  arterio- 
sclerosis the  nerves  of  the  vessels,  especially  the 
vasoconstrictors,  are  much  easier  stimulated  than 
is  normally  the  case,  and  that  functional  hyper- 
irritation  is  often  a  prominent  feature  in  an 
anatomical  affection  of  the  vessels.  Vertigo  and 
periodic  headache  are  part  of  the  symptoms  of 
cerebral  arteriosclerosis  which  manifest  them- 
selves in  the  union  of  these  two  factors.  This 
explains  also  the  fact  that  in  abnormal  vaso- 
motoric  conditions  both  vasoparalysis  and  vaso- 
constriction may  give  rise  to  the  same  manifes- 
tations of  headache.  That  vasoconstriction  is 
the  provoking  cause  is  proved  by  the  fact  that 
fainting  is  often  associated  with  it. 

Abnormal  innervation  of  the  vessels,  abnormal 
distribution  of  the  blood  either  due  to  anemia 
or  hyperemia  of  the  cerebral  arteries,  are  indu- 
bitably the  originating  factors  of  that  headache 
which  is  so  common  in  overworked  men  and 


HEAD  533 

women  in  whom  no  anatomical  affection  exists. 
The  slightest  excess,  even  a  small  dose  of  alcohol, 
or  a  pipeful  of  tobacco  may  bring  on  the  head- 
ache in  such  people. 

Vasomotoric  disturbance  is  the  excitant  of 
headaches  in  menstruating  women,  but  the  char- 
acteristics of  a  concomitant  migraine  are  not 
present  in  these  cases.  We  observe  the  same 
in  young  girls  at  the  time  of  pubescence,  when 
vicarious  bleeding  from  the  nose  is  coupled  with 
the  pains  in  the  head  before  the  menses  have 
assumed  their  proper  rhythm.  Nausea,  vomit- 
ing, giddiness  come  along  with  the  headache  and 
disappear  with  the  epistaxis. 

An  anatomical  lesion  in  the  sympatliicus  is 
another  originator  of  vasomotoric  pains  in  the 
head.  If  the  complaint  is  on  the  right  side  of 
the  head  and  is  combined  with  pains  in  the  right 
arm  and  hypodrosis  in  the  right  axilla,  then  in 
a  case  of  aortic  aneurysm  it  can  only  be  due  to 
pressure  on  the  marginal  trunk  of  the  right 
sympathicus  or  to  perineuritis  of  the  sympathi- 
cus  arising  from  periaortitis. 

In  a  case  of  ulcus  ventriculi  I  had  occasion 
to  observe  the  following  symptoms.  The  ulcer- 
ous attack,  came  on  year  after  year  with  increas- 
ing virulence ;  with  them  pains  in  the  right  inside 
of  the  head  set  in,  but  disappeared  with  the 
removal  of  the  intestinal  trouble  by  gastro- 
enterostomy. 


534  GENERALIZED   PAIN 

Some  patients  who  suffer  from  muriatic  an- 
acidity  are  subject  to  headaches  when  the  stom- 
ach is  empty.  It  goes  away  with  the  intake  of 
food. 

Still  another  cause  for  headache  we  find  in 
arterial  hypertension  and  in  all  morbid  processes 
that  lead  to  it  no  matter  whether  the  hyper- 
tension itself  is  essential  or  deuteropathic,  pain- 
ful or  painless  in  its  nature.  The  seat  of  the 
pains  in  the  head  may  vary  according  to  circum- 
stances. If  they  are  connected  with  a  protracted 
case  of  arterial  hypertension  they  are  wont  to 
set  in  after  midnight,  i.e.,  in  the  early  morning 
hours  or  at  awakening.  In  some  cases  they  are 
the  only  sign  of  the  existing  disease,  but  in 
others  they  are  associated  with  sleeplessness, 
dyspnea,  precordial  pains  (pressure,  anginoid 
troubles,  polyuria). 

Headache  in  arterial  hypotension  combined 
with  weak  heart  action  or  venous  congestion 
I  have  never  been  able  to  observe. 

If,  what  is  today  called  "pseudouremia"  com- 
prises also  the  vessel  crises  described  above,  then 
it  includes  also  the  same  list  of  symptoms  (head- 
ache, giddiness,  transitory  amaurosis,  aphasia, 
strokes,  cramps,  Cheyne-Stokes'  respiration, 
mental  disturbances),  and  also  increased  cere- 
bral pressure  owing  to  edema  (chloremia)  which 
may  be  spotted  by  lumbar  pressure. 

Needless  to  say  headache  is  a  steady  com- 


HEAD  535 

panion  of  epilepsy.  It  comes  at  times  in  the 
shape  of  a  sudden  stroke  on  the  head,  and  travels 
in  company  with  dizziness,  nausea,  vomiting, 
temporary  loss  of  consciousness.  Without  these 
symptoms  we  have  rather  a  case  of  petit  mat 
before  us.  The  pains  in  the  head,  as  a  rule,  go 
away  after  the  epileptic  seizure.  I  may  point 
out  here  the  fact  that  cocaine  is  contraindicated 
as  its  administration  may  provoke  an  epileptic 
fit  or  at  any  rate  an  epileptic  aura  including 
giddiness,  nausea,  vomiting,  palpitation  of  the 
heart,  dyspnea,  tremor  and  sever  headache. 

Pain,  especially  in  the  occipital  and  vertex 
region,  is  a  frequent  and  lasting  complaint  dur- 
ing the  whole  time  of  mental  stupor  in  mycc- 
edema.  The  evidence  of  psychic  and  cutaneous 
changes,  hypothermia,  the  thickened  tongue  and 
the  effects  of  thyreoid  extract  should  clear  the 
situation  without  much  delay. 

The  same  holds  good  in  cases  of  hypothyreoid- 
ism  which  often  simulates  neurasthenia  or  ane- 
mia. Dryness  and  roughness  of  the  skin,  trophic 
disturbances  in  the  hair  and  the  nails,  lassitude, 
hypothermia,  insufficient  perspiration,  moodi- 
ness,  and  treatment  with  thyreoid  extract,  apply 
here  also. 

Adrenal  insufficiency  and  its  substitute  Addi- 
son's  disease,  follow  in  line.  In  both  diseases 
headache  is  of  a  very  severe,  piercing  character 
not  only  during  the  whole  course  of  the  disease 


536  GENERALIZED   PAIN 

but  especially   also   in  the   "pseudomeningitic" 
final  stadium. 

True  (functional)  orthototic  albuminuria  in 
youthful  persons  lays  claim  to  headache,  early 
fatigue,  despondency,  giddiness  and  proneness 
to  fainting.  The  headache  in  these  cases  may 
have  in  part  a  vasomotoric  basis,  but  it  seems 
to  me  rather  due  to  some  abnormal,  constitu- 
tional, degenerative  condition.  The  diagnosis  is 
extremely  easy  to  make,  but  according  to  my 
own  experience  it  is  rarely  made.  If  a  differ- 
entiation is  to  be  made  between  the  lesional  and 
merely  functional  forms  of  the  disease  we  should 
look  for  granulated  or  epithelial  cylindroids, 
large  numbers  of  erythrocytes  and  a  typical 
chondritis. 

Headache  Due  to  Distant  Causes 

Headaches  due  to  ocular  conditions.  Over- 
strained accommodation  in  refraction  anomalies, 
in  hypermetropia  and  astigmatism,  abnormal 
convergent  straining  (exophoria),  inflammatory 
affections  of  the  eyes,  especially  glaucoma,  work- 
ing by  bad  light,  all  these  are  possible  causes  of 
pains  in  the  head.  In  arthenopia  the  patient 
complains  also  of  pains  in  and  above  the  eyes, 
also  in  the  forehead,  that  the  headache  is  ag- 
gravated by  prolonged  work,  stops  during  the 
night  time,  and  when  present  resembles  a  supra- 
orbital  neuralgia.  When  in  glaucoma  vomiting 


HEAD  537 

is  witnessed  the  erroneous  diagnosis  of  intra- 
cranial  disease  with  increased  cerebral  pressure 
is  apt  to  creep  in  much  to  the  detriment  of  the 
patient.  It  is  not  unlikely  that  some  cases  of 
adolescence  and  puberty  headache  are  attribu- 
table to  overstrain  of  the  visual  apparatus. 

The  same  as  in  eye  troubles,  so  the  pains  are 
located  in  the  forehead  when  the  frontal  sinus 
is  implicated  either  in  a  suppurative  or  inflam- 
matory process.  They  are  apt  to  create  the 
impression  of  a  supraorbital  neuralgia  and  are 
of  a  diffuse  character,  generally  felt  at  the  root 
of  the  nose  between  the  eyebrows,  chiefly  in  the 
early  morning  hours.  We  shall  not  go  astray 
in  the  diagnosis  if  we  keep  a  careful  watch  on 
the  following  points:  not  only  the  nerve  along 
its  course  is  tender  to  pressure,  but  the  whole 
frontal  area  is  sensitive  on  percussion,  the  pa- 
tient complains  of  a  raging,  throbbing  pain  in 
the  forehead  at  large,  the  nose  is  obstructed, 
previous  or  parallel  affections  of  the  nasal  cavi- 
ties (acute  or  chronic  rhinitis,  the  usual  secre- 
tions are  hardened,  polypus,  spurs,  spikes  or 
other  deformities  of  the  septum  or  bones). 
Adrenalin  or  cocaine  give  relief.  Thorough 
examination  of  the  nasal  cavities  and  transillu- 
mination  of  the  frontal  sinus  are  prerequisites. 

All  this  applies  with  like  force  to  acute  as  well 
as  chronic  diseases  of  the  sphenoid  and  the  tur- 
binated  bones,  also  to  any  affections  of  the 


538  GENERALIZED   PAIN 

accessory  nasal  cavities.  In  catarrhal  inflam- 
matory conditions  the  pains  are  sometimes  very 
severe  and  distressing.  Influenza  is  especially 
marked  by  dull  pains  in  the  vertex  region  when 
they  are  due  to  ethmoiditis,  but  when  arising 
from  the  sphenoid  sinus  they  settle  behind  the 
eyes  and  are  made  worse  by  mental  work  or 
physical  exertion. 

Pains  in  the  anthrum  of  Highmore  radiating 
to  the  head  are  likely  due  to  some  suppurative 
process  in  the  maxillary  sinus  giving  rise  to 
meningeal  or  phlebitic  complications. 

Diseases  of  the  outer  or  the  inner  ear  (furun- 
culosis,  foreign  bodies)  always  afflict  the  patient 
with  pains  in  the  head.  Sometimes  they  are  only 
of  local  signficance  within  the  radius  of  the 
affected  part  of  the  ear,  but,  as  a  rule,  they 
permeate  the  whole  of  the  corresponding  side  of 
the  head.  If  of  a  diffuse  nature  they  settle  also 
in  the  occiput,  rarely  involving  the  entire  cranial 
cavity.  And  again,  they  attack  the  region  of 
the  visual  organs  with  local  pressure  and  deli- 
cacy to  percussion  around  the  ear,  especially 
above  the  mastoid  process  in  inner  affections. 
In  acute,  and  more  so,  in  chronic  lesions  of  the 
middle  ear  (cholesteoma,  suppuration  of  the 
bones  of  the  ear)  they  involve  the  brain,  and 
form,  perhaps,  the  primary  symptom  of  a  sinus 
phlebitis,  cerebral  abscess,  or  purulent  menin- 
gitis. Lumbar  puncture,  or  eventually  trephin- 


HEAD  589 

ing,  often  stop  these  very  distressing  headaches 
efficiently. 

Malignant  growths  and  other  affections  in 
the  larynx  or  pharynx  are  also  originators  of 
bothersome  cephalalgias. 

Retronasal  angina  and  morbid  conditions  of 
the  tonsils  and  of  the  teeth  belong  here.  Acute 
occipital  neuralgia  with  pains  ranging  from  the 
nape  of  the  neck  to  the  occiput  point  to  acute 
angina.  Chronic  pharyngeal  affections  (ade- 
noids, tuberculosis  or  carcinoma  of  the  pharyn- 
geal wall)  give  room  to  chronic  pains  in  the 
occipital  or  frontal  regions.  Headaches  arising 
from  sick  teeth,  especially  from  caries  of  the 
molars  or  the  difficult  passage  of  a  wisdom 
tooth,  are  generally  localized  in  the  temporal 
area,  but  may  also  be  in  the  ear  itself  (simulat- 
ing an  attack  of  otitis)  or  in  front  of  the  ear 
with  irradiations  into  the  corresponding  cheek, 
and  often  supersede  in  violence  the  toothache 
itself. 

Among  the  affections  of  the  oral  cavities  I 
wish  to  mention  chronic  infectious  conditions 
such  as  chronic  purulent  tonsilitis,  chronic  den- 
tal stasis,  all  of  which  may  lead  to  chronic  sepsis, 
loss  of  appetite,  pallor,  subfebrile  temperature, 
chills,  sweats,  and  a  general  feeling  of  indis- 
position and  in  consequence  to  toxico-septic 
headaches  which  disappear  with  the  removal  of 
the  originating  cause. 


540  GENERALIZED   PAIN 

Another  focus  from  which  headaches  derive 
their  origin  we  find  in  the  internal  organs,  espe- 
cially those  in  which  urinalysis  is  demanded. 

In  kidney  affections  headache  easily  proves 
the  distinguishing  sign  of  uremia,  pointing  often 
to  the  probability  of  an  existing  cerebral  edema 
running  a  parallel  course  with  the  edematous 
condition  (nephrosis),  or  of  cerebral  arterio- 
sclerosis (pseudouremia)  or  of  azotemia.  The 
occiput  is  the  habitat  of  uremic  headache  which, 
like  all  the  other  symptoms  of  uremia,  is  asso- 
ciated with  vomiting,  and  generally  comes  on 
in  the  morning.  That  is  the  reason  why  it  is 
so  frequently  mistaken  for  idiopathic  migraine. 
A  proper  consideration  of  the  other  uremic 
symptoms,  urine,  blood  (residuary  nitrogen) 
and  blood  pressure  tests  should  obviate  all  er- 
rors. For  quite  some  time  I  have  held  the 
opinion  that  headache  in  chronic  nephritis  is  of 
toxic  origin.  No  doubt  a  good  deal  of  it  is 
due  to  high  pressure  tension.  Moreover,  in 
nephritis  with  or  without  uremia  there  are  many 
complications  which  may  give  rise  to  pain  in 
the  head,  such  as  uremic  meningitis,  uremic  cere- 
bral edema,  cerebral  hemorrhage,  the  possibility 
of  encephalomalacia  of  thrombotic  or  embolic 
origin,  inclination  to  internal  hemorrhagic  pachy- 
meningitis.  Headache  may  also  set  in  at  the 
incipient  stages  of  acute  glomerulonephritis  as 
a  manifestation  of  acute  infection. 


HEAD  541 

Headache  will  also  occur  as  an  "anaphylactic" 
phenomenon  in  the  rapid  resorption  of  hydropic 
fluid  in  edemata  and  in  hepatic  insufficiency 
(hepatargia,  anhepathia).  In  the  latter  case, 
however,  they  are,  according  to  my  own  expe- 
rience, more  of  secondary  importance  than  in  the 
other  cerebral  disturbances  (numbness,  cramps) 
and  in  the  manifestations  of  hemorrhagic  dia- 
thesis. 

In  every  kind  of  gravidity  toacicosis  headaches 
will  be  present.  They  are  complementary  symp- 
toms in  hyperemesis  gravidarum,  and  still  more 
so  in  eclampsia  gravidarum  and  atypical  toxi- 
coses in  the  pregnant.  The  latter,  as  a  rule, 
starts  in  with  cerebral  symptoms,  with  icterus, 
oliguria,  even  anuria  and  also  hematuria,  nearly 
always  accompanied  by  albuminuria  and  cylin- 
druria  and — in  contradistinction  to  eclampsia— 
without  spasms  leading  to  coma.  But  I  have 
my  doubts  whether  these  headaches  which  mani- 
fest themselves  in  some  women  at  the  beginning 
of  every  pregnancy,  can  be  always  reduced  to 
toxic  origin. 

In  diabetes  melUtus  some  patients  suffer  from 
headache.  Sometimes  it  is  a  generalized  pres- 
sure in  the  head,  but  frequently  it  assumes  the 
character  of  a  well  defined  pain,  mostly  in  the 
frontal  region,  often  enough,  indeed,  in  the  very 
center  of  the  cranium.  At  times  it  resembles 
neuralgic  pain — all  diabetics  are  inclined  to  neu- 


542  GENERALIZED   PAIN 

ralgia.  This  is  mainly  an  expression  of  the 
existing  acidosis  often  making  its  appearance 
only  in  the  night  time  or  at  any  rate  with  more 
pronounced  severity  at  that  period.  It  is  worthy 
of  note  that  very  severe,  at  times,  insufferable 
pain  in  the  head  in  the  course  of  diabetes  melli- 
tus  is  often  the  forerunner  or  admonitory  sign 
of  a  diabetic  coma.  The  diagnosis  will  be  guided 
by  the  concurrent  clouding  of  consciousness,  by 
epigastralgia  diabetica,  meteorism,  deep,  re- 
tarded breathing  and  above  all,  by  a  correct 
urinalysis  showing  the  presence  of  acid  intoxica- 
tion of  the  organism  (acetic  acid,  oxybutyric 
acid,  increased  ammonia  content). 

The  situation  may  become  more  complicated 
when  the  coma  is  compensated  by  an  acute 
affection  which  alone  gives  rise  to  headache.  I 
remember  a  patient  who  had  been  suffering  from 
diabetes  mellitus  of  long  standing  and  who  sud- 
denly became  feverish  owing  to  an  acute  peri- 
ostitis in  an  upper  molar.  The  second  day  he 
complained  of  violent  pain  in  the  head  attribut- 
ing it  to  the  diseased  tooth.  But  a  careful 
clinical  observation  soon  showed  that  the  real 
cause  was  a  coma  which  developed  during  the 
next  twenty-four  hours.  On  the  other  hand  an 
internal  hemorrhagic  pachymeningitis  or  a  tu- 
berculous meningitis  may  be  the  inciting  element 
of  terminal  headaches  in  diabetics. 

Chronic  obstipation  is   another   source   from 


HEAD 

which  pain  in  the  head  may  spring  in  the  shape 
of  a  feeling  of  pressure,  neuralgiform  or  real, 
violent  neuralgic  pain  either  in  the  trigeminal 
or  in  the  occipital  region.  Many  of  these  obsti- 
nate cases  yield  to  an  efficient  rigorous  cathartic 
treatment. 

In  cases  where  obstipation  is  in  the  main  only 
coupled  with  pressure  in  the  head  a  diagnosis 
for  intestinal  auto-intoxication  is  in  my  opinion 
not  warranted.  I  would  rather  seek  the  cause 
in  an  existing  neurosis,  which  would  also  explain 
the  complaints  of  lassitude,  dizziness,  restless 
nights,  etc. 

Retention  of  flatus,  intestinal  flatulent  dys- 
pepsia following  chronic  intestinal  catarrh  are 
apt  to  produce  pain  in  the  occipital  region. 
Diagnosis  is  rendered  easy  by  means  of  adju- 
vants. 

Gout,  resp.  uratic  diathesis,  is  not  of  great 
moment  in  this  connection.  In  my  own  prac- 
tice I  have  not  been  able  to  substantiate  the 
existence  of  specific  gouty  headaches  or  neural- 
gias either  in  the  occipital  or  trigeminal  region. 
When  headache  and  gout  run  concurrently  I 
should  prefer  to  attribute  the  headache  rather 
to  neurasthenia  which  thrives  in  gouty  subjects, 
or  to  arteriosclerosis  of  the  cerebral  vessels,  or 
to  disturbances  in  the  intestinal  canal,  to  arterial 
hypertension  or  insufficiency  of  the  kidneys, 
unless  other  causes  (alcohol,  nicotine,  etc.)  are 


544  GENERALIZED   PAIN 

in  evidence,  barring,  however,  headaches  which 
are  the  forerunners  or  companions  of  acute  arti- 
cular gouty  attacks  (podagra). 

Headache  is  also  conditioned  by  not  a  few  of 
the  exogenous  toxins  (coffee,  tea,  nicotine,  lead, 
arsenic).  All  poisons  which  produce  cerebral 
morbid  symptoms  will  also  cause  headaches  (nar- 
cotics, carbonic  oxid,  botulism,  etc.).  Similar 
excitants  of  the  so-called  vasoparalytic  headache, 
are  alcohol,  chloroform,  amylnitrate,  nicotine. 
The  prolonged  use  or  misuse  of  certain  toxic 
substances  may  lead  to  headaches  (tea,  coffee). 
They  all  are  the  producers  of  pseudoneuras- 
thenic  troubles,  i.e.,  pain  in  the  occipital  region, 
pressure  in  the  head,  dizziness,  anginoid  attacks, 
fainting  fits,  profuse  perspiration,  gastralgic 
crises,  pallor,  emacition,  obstipation,  aphasia, 
hemiparesthesia,  etc.  Presence  of  tremor,  dis- 
like for  tobacco,  etc.,  should  assist  the  diagnosis. 
(That  first  smoke!) 

Excess  in  the  use  of  the  weed  may  also  be 
the  father  of  other  pains  in  the  head  such  as 
migraine,  neurasthenic,  hysterical  or  arterioscle- 
rotic  pains,  likewise  of  headaches  caused  by  cere- 
bral affections,  e.g.,  meningitis  serosa. 

Chronic  lead  poisoning  may  easily  be  mistaken 
for  some  kind  of  neurasthenia  as  both  have  in 
common  the  manifestations  of  slight  pressure  in 
the  head,  sensation  of  oppression,  weakening  of 
memory  and  general  lassitude.  This  error  will 


HEAD  545 

creep  in  when  the  possible  cause  of  chronic  lead 
poisoning  is  far  removed  from  the  minds  of 
patient  and  physician  as  well,  for  in  many  trades 
lead  is  only  used  in  small  quantities,  for  instance, 
in  cosmetics.  But  findings  of  the  blue  line, 
pallor,  presence  of  punctuated  erythrocytes,  of 
colicky  pains  in  the  bowels  or  of  arthralgia,  like- 
wise muscular  weakness  in  the  radial  region 
should  decide  the  correct  diagnosis.  These 
symptoms  must  also  be  watched  when  saturnine 
encephalopathy  lies  in  the  wake  of  plumbism. 
In  the  differential  diagnosis  between  lead  poison- 
ing and  leptomeningitic  headache  is  of  little 
moment,  but  in  progressive  paralysis  (alcohol 
paralysis)  it  becomes  a  determining  factor, 
viz.,  presence  of  pseudoneurasthenic,  moderately 
acute  pressure  in  the  head,  as  against  most  vio- 
lent headaches  in  the  former. 

Arsenic  poisoning,  especially  with  arsenous 
hydrogen,  is  also  associated  with  headaches,  espe- 
cially in  the  forehead,  with  lassitude,  dizziness, 
sleeplessness  and  loss  of  appetite.  The  presence 
of  inflammatory  lesions  of  the  conjunctiva  and 
respiratory  mucous  membrane,  gastrointestinal 
symptoms,  neuritic  manifestations  preferably  in 
the  lower  extremities,  with  well-defined  strong 
pains  and  trophic  disturbances  in  the  skin,  and 
dermoid  formations,  and  in  herpes  zoster  awaken 
the  thought  of  arsenic  poisoning.  Laboratory 
tests  of  feces  and  urine  furnish  the  final  proof. 


546  GENERALIZED   PAIN 

I  remember  the  case  of  a  patient  who  was 
afflicted  with  severe  arteriosclerosis  and  a  granu- 
lar kidney  and  strong  arterial  hypertension. 
Periodically  he  suffered  for  weeks  from  want 
of  appetite,  nausea,  vomiting,  headaches,  cramps 
in  the  calves,  a  peculiar  sweetish  taste  in  the 
mouth.  The  patient  who  possessed  unusual  in- 
telligence suggested  arsenic  poisoning.  I  myself 
diagnosed  chronic  uremia  because  the  patient's 
breath  had  the  characteristic  uremic  odor.  The 
laboratory  tests  showed  traces  of  arsenic  in  feces 
and  urine.  Upon  closer  investigation  the  real 
cause  of  the  trouble  was  discovered.  He  had  a 
number  of  stuffed  birds  and  also  upholstered 
chairs  in  his  room  all  of  which  contained  arsenic 
as  a  protection  against  moths.  Still  I  adhered 
to  my  diagnosis  of  chronic  uremia  but  compli- 
cated with  arsenic  poisoning. 

Mention  must  be  made  here  of  nitrobenzene 
poisoning  (an  imitation  oil  of  bitter  almonds, 
also  called  essence  of  mirbane,  used  in  the  manu- 
facture of  perfumes).  Predominant  signs  are: 
headache,  transitory  disturbances  in  the  central 
nervous  system  and  manifestation  of  hemolysis 
(icterus). 

Very  stubborn  headaches  will  be  encountered 
in  workers  with  vanilla,  carbon  disulphid  and 
quicksilver. 

Raging  headaches  will  at  times  follow  spinal 


HEAD  547 

anesthesia,  generally  accompanied  by  sleepless- 
ness and  delirious  or  pseudomeningitic  affects. 

It  is  proper  to  mention  here  also  poisoning  by 
carbonic  monoxid  gas.  It  develops  from  leaky 
gas  pipes  in  the  gas  works  (for  heat  or  light). 
The  symptoms  are:  headache,  dizziness,  lassi- 
tude, sleeplessness,  numbness,  epileptoid  attack, 
and  also  glycosuria.  It  is  of  value  to  know 
that  the  pains  in  the  head  endure  in  the  winter, 
but  disappear  in  the  summer  time.  Spectro- 
scopic  examination  of  the  blood — it  need  not  be 
positive — will  confirm  the  finding.  Similar  con- 
ditions will  be  encountered  in  laundries  where 
gas  is  used. 

Reverting  to  the  internal  organs  again,  head- 
aches will  be  prominent  in  acute  and  chronic 
dyspepsia  or  in  gastritis.  In  constant  or  only 
sporadic  dilatation  of  the  stomach  the  pains  are 
by  preference  localized  in  the  forehead;  by 
icterus  (no  matter  of  what  origin)  they  consist 
more  of  pressure  in  the  head.  It  is  selfevident 
that  in  dyspepsia  and  gastritis  they  possess  no 
differential  diagnostic  significance  so  far  as 
neurosis  of  the  stomach  is  concerned,  because 
headache  and  pains  in  the  lumbo-sacral  region 
are  common  companions  in  all  kinds  of  organic 
neurosis. 

Chronic  cholelithiasis  (gallstone  in  the  gall- 
bladder) deserves  special  mention  here.  It  ap- 
pears often  in  the  frame  of  a  chronic  dyspepsia. 


548  GENERALIZED   PAIN 

There  is  a  feeling  of  pressure  in  the  stomach, 
generally  one-half  to  one  hour  after  meals,  espe- 
cially after  a  heavy  banquet,  of  surfeit,  followed 
by  belching,  ructus,  oppression  and  headache, 
dizziness  and  the  sensation  of  cold  pervading 
the  body,  and  chronic  obstipation.  (Particulars 
will  be  found  in  my  book  "Abdominal  Pain," 
Rebman  Company,  New  York.)  The  same 
may  be  the  case  in  relapsing  cholecystitis. 

Intestinal  parasites  (tenia,  trichocephalus, 
ascarides,  oxyuris)  also  cause  chronic  dyspeptic 
troubles  (loss  of  appetite,  bulemia,  hungerpains, 
vomiting,  diarrhea)  with  accompanying  pseudo- 
neurasthenic  manifestations,  principally  head- 
aches, also  vertigo,  palpitation  and  emaciation. 
Repeated  tests  of  the  feces  for  the  eggs  of  the 
parasites  will  clear  the  situation. 

Headaches  play  a  prominent  role  in  the  inter- 
mittent flow  of  gastric  juice  (intermittent  hyper- 
acidity of  the  stomach)  called  by  Rossbach 
"nervous  gastroxynsis."  Violent  headaches,  se- 
vere gastralgias,  copious  vomiting  of  hyperacid 
stomach  contents  are  the  principal  symptoms. 
Some  of  these  cases,  it  seems  to  me,  are  only 
a  migraine  with  prominent  gastric  manifesta- 
tions, whilst  others  rather  possess  the  dignity  of 
gastric  crises  (for  instance  in  tabes)  pointing 
ultimately  to  some  functional  or  anatomical  dis- 
order. 

In  affections  of  the  respiratory  tract  headaches 


HEAD  549 

are  not  of  frequent  occurrence.  If  present  they 
are  very  likely  due  to  some  vascular  stasis  con- 
ditioned by  repeated  fits  of  coughing,  defective 
pulmonary  ventilation  or  by  insufficiency  in  the 
right  heart. 

If  headaches  make  a  sudden  appearance  in 
bronchiectasy,  or  in  chronic  interstitial  pneu- 
monia, or  perhaps  also  in  cladothrix,  they  will 
remind  us  of  possible  complications  with  an 
abscess  in  the  brain,  chiefly  in  the  cerebellum. 

Angina  pectoris  also  brings  about  headaches, 
chiefly  in  the  left  hemisphere.  The  fact  that 
they  nearly  always  emanate  from  the  retroster- 
nal  pain  center  spreading  thence  over  nape  and 
neck  into  the  occiput  will  render  the  diagnosis 
easy.  Unilateral  headaches  will  also  be  observed 
in  vasomotoric  angina  pectoris.  Cf.  chapter  on 
"Pains  in  the  Heart." 

Headaches  coming  in  successive  attacks  should 
direct  our  thought  to  cardiac  dissociation.  But 
if  we  are  confronted  by  a  functional  disturbance 
of  the  heart  which  may  also  lead  to  similar  cere- 
bral symptoms  such  as  heartblock  (see  "Disturb- 
ances of  the  Heart  Rhythm"),  then  headaches 
accompanied  by  dizziness,  befogged  conscious- 
ness and  nausea  may  constitute  the  sole  sign  of 
a  cardiac  affection.  They  would  then  be  due 
to  a  defect  in  the  blood  supply  of  the  brain, 
i.e.,  a  periodical  cerebral  anemia.  It  is  acute 
ischemia  of  the  brain  that  produces  the  pain. 


550  GENERALIZED   PAIN 

Headache,  particularly  in  the  occipital  region, 
sometimes  only  in  the  form  of  a  feeling  of  pres- 
sure in  the  back  of  the  head,  often  coupled  with 
dizziness,  tinnitus  and  fainting  fits,  may  be  the 
initial  sign  of  incipient  chronic  insufficiency  of 
the  heart.  (Cf.  under  that  heading.) 

Headaches  during  the  period  of  pubescence, 
cephalea  adolescentium,  chiefly  in  the  male,  are 
principally  located  in  the  frontal  region,  milder 
in  the  morning  but  more  acute  in  the  evening, 
very  bothersome  and  interfering  with  even  light 
mental  work.  They  may  originate  from  ade- 
noids. Otherwise  we  must  consider  age,  abnor- 
mally quick  physical  growth,  disturbances  in  the 
heart  (cardiac  debility,  palpitation,  small  caliber 
of  the  arteries)  and  vascular  innervation,  dizzi- 
ness, epistaxis,  early  fatigue  in  bodily  exercise, 
orthotic  albuminuria,  in  some  cases  asthenopia, 
in  others  insufficient  arterial  circulation  in  the 
brain,  retarded  cerebral  development.  All  these 
conditions  may  be  the  active  cause  of  "pseudo- 
neurasthenic"  cephalic  pains.  They  are  called 
school  headaches  and  may  persist  during  the 
whole  scholastic  life.  This  "school  anemia,"  as 
it  is  also  called,  is,  no  doubt,  due  to  an  abnormal 
rigidity  of  the  arteries  originating  from  an 
increased  vascular  muscle  tonus.  Palpation  of 
the  radial  arteries  will  prove  this.  These  pains 
are  also  accompanied  by  other  vasomotoric  dis- 
turbances, among  them  cold  feet  and  hands, 


HEAD  551 

palpitation  of  the  heart,  cardiac  pains  and  faint- 
ing spells,  even  anginoid  troubles.  In  overexer- 
tion  of  the  mental  faculties  a  peculiar  pain  will 
be  sometimes  observed.  The  cause  for  this  may 
be  found  in  the  developing  process  of  the  cranial 
sutures  and  may  assume  the  form  of  a  high 
grade  pressure  sensibility  (sutured  neuralgia). 

Headaches  in  childhood  may  be  caused  by  any 
of  the  following  conditions,  viz.,  defective  hy- 
gienic conditions,  badly  ventilated  dormitories 
or  bedrooms  or  classrooms,  sitting  too  near  the 
heating  apparatus,  too  early  rising  in  the  morn- 
ing, insufficient  sleep,  underfeeding  at  the  break- 
fast table  or  going  away  with  an  empty  stomach, 
and  last  but  not  least  to  overstrain  of  the  eyes 
in  reading.  These  conditions  may  have  the  same 
effect  even  on  grown  up  people. 

Persons  who  work  by  artificial  light  especially 
when  the  gas  jet  or  the  electric  bulb  is  too  near 
the  crown  of  the  head  very  often  complain  of 
headaches.  These  pains  belong  to  the  same 
category  as  sunstroke  or  heatstroke  and  are 
frequently  accompanied  by  the  same  symptoms, 
dizziness,  tinnitus  aurium,  vomiting,  trembling 
of  the  hands,  fibrillary  muscular  contractions  or 
twitchings,  even  convulsions,  subsequent  retarded 
pulse,  unconsciousness,  stertorous  breathing,  de- 
lirium. Solar  dermatitis  is  not  excluded. 

Violent  hammering  in  the  cranium  and  a  feel- 
ing of  pressure  in  the  head  are  concomitant 


552  GENERALIZED   PAIN 

symptoms  of  heatstroke  together  with  dryness  in 
the  mouth,  physical  debility,  mental  fatigue, 
mental  numbness,  indifference  to  surroundings, 
rise  in  body  temperature,  unsteady  gait,  bluish 
tint  in  a  puffed  face  and  hot,  dripping  skin. 
Sudden  coma  and  utter  collapse,  spasmodic 
muscular  movements,  anuria,  arrest  of  perspira- 
tion, feint,  thready,  finally  disappearing  pulse, 
suppressed  breathing,  vomiting,  diarrhea  and 
general  convulsions.  Persons  who  recover  from 
an  attack  of  sunstroke  frequently  complain  for 
a  long  time  afterwards  of  headaches  and  nervous 
( pseudohy sterical )  disorders. 

Reflex  actions  from  the  sexual  sphere  may 
also  cause  headaches.  Acute  and  chronic  infec- 
tious diseases  are  often  accompanied  by  head- 
aches which  are  very  intensive  in  some  of  these 
affections,  e.g.,  in  pernicious  or  tropical  malaria, 
plague,  yellow  fever,  blackwater  fever,  recur- 
rent fever,  exanthematous  fever.  In  the  last 
named  disease  the  pain  is  at  times  so  severe 
that  the  patient  complains  about  nothing  else 
than  that  "terrible  pain  in  head"  especially  in 
the  top  and  the  frontal  region.  These  pains  are 
at  times  coupled  with  vertigo  and  broadcast  into 
the  lumbar  and  sacral  regions,  into  the  calves 
and  articular  sections. 

Infectious  cerebral  and  spinal  diseases,  ery- 
sipelas, smallpox,  epidemic  parotitis,  Wolhy- 
nian  fever,  abdominal  typhoid,  paratyphoid  and 


HEAD  553 

influenza,  all  are  originators  of  headaches.  In 
typhoid  and  influenza  the  pains  in  the  head  set 
in  with  the  incipient  stages  of  the  disease — in 
typhoid  they  affect  also  the  hearing — and  are  of 
a  purely  toxic  infectious  character.  Recent 
research  ascribes  them  to  hypertension  of  the 
cerebrospinal  fluid.  In  consequence  they  are 
much  ameliorated  by  lumbar  puncture,  but  they 
continue  with  the  progressing  infection  until  the 
clouding  of  the  sensorium  renders  the  patient 
less  susceptible  to  pain.  But  if  the  patient 
despite  this  numbness  of  the  sensorium  continues 
to  complain  of  steadily  increasing  headaches  it 
will  be  advisable  to  look  for  complications  in  the 
cranial  sphere.  Influenzal  cephalalgia  bears  the 
character  of  inflammatory  pain  due  to  infectious 
lesions  in  the  nasal  cavities,  or  that  of  neuralgic 
pain. 

The  differential  diagnosis  between  influenza 
and  hay  fever  depends  upon  the  consideration 
of  the  pain  in  the  head.  Quite  true,  the  hay 
fever  patient  also  complains  about  dullness  and 
pain,  mainly  in  the  forehead,  severely  exacer- 
bated by  the  typical  attacks  of  sneezing.  But 
they  are  surpassed  by  the  initial  burning  and 
itching  in  the  eyes  and  nose,  whilst  in  influenza 
the  headache  together  with  the  rhinitic  symptoms 
will  be  found  among  the  predominant  manifesta- 
tions. 

In  Pappataci  fever,  which  also  may  be  mis- 


554  GENERALIZED   PAIN 

taken  for  the  grippe,  the  streaky  injection  of  the 
conjunctiva,  congestion  of  the  face,  leucopenia 
and  the  local  conditions  will  facilitate  the  diag- 
nosis. 

Infectious  meningitis  is  another  source  of 
headaches.  In  the  abortive  forms  of  epidemic 
meningitis  mild  headaches  are  about  the  only  com- 
plaint made  by  the  victim.  That  circumstance 
renders  the  diagnosis  rather  difficult,  particularly 
so  when  the  existence  of  such  an  epidemic  has 
not  yet  been  established.  Nevertheless,  it  remains 
an  important  sign. 

In  these  cases  it  is  well  to  watch  the  other 
symptoms  even  though  they  also  be  developed 
in  a  rudimentary  form  only.  Among  them:  a 
slight  hammering  in  the  cranium,  stiffness  in 
the  neck,  a  touch  of  pain  in  the  scruff,  indica- 
tion of  Kernig's  signs,  percussion  in  the  spinal 
column,  leucocytosis,  slight  angina,  bronchitic 
or  gastric  disturbances.  Our  suspicions  will  be 
confirmed  by  bacterial  examination  of  the  nasal 
and  faucial  secretions  and  lumbar  puncture 
(increased  lumbar  pressure,  turbidity  in  the 
spinal  fluid,  intracellular  meningococci).  But 
we  must  not  overlook  the  fact  that  in  these  very 
cases  the  meningococcus  is  generally  not  present 
at  all  or  at  least  not  in  its  characteristic  form 
and  that  the  lumbar  fluid,  though  rich  in  albu- 
min, is  quite  clear  in  appearance.  The  final 
diagnosis  must  be  made  at  the  bedside. 


HEAD  555 

The  recurrence  of  intensive  pains  in  the  head 
during  the  time  of  an  epidemic  of  meningitis 
points  to  the  development  of  hydrocephalus,  or, 
let  us  say,  to  that  of  a  serous  chronic  meningitis 
as  a  sequel  to  acute  epidemic  meningitis. 

There  are  other  infectious  diseases  in  which 
headache  is  one  of  the  foremost  typical  manifes- 
tations, for  instance,  walking  typhoid.  Many 
of  these  cases  are  at  first  diagnosed  as  influenza 
or  lobular  pulmonary  catarrh,  until  a  severe 
ambulant  melena  throws  the  patient  upon  the 
sick  bed  or  even  into  a  premature  grave.  We 
shall  do  well  if  in  such  doubtful  cases  we  keep 
our  eyes  open  for  initial  nosebleeds,  obvious 
bradycardia,  a  possible  minor  splenic  tumor, 
positive  diazo  reaction,  a  rapidly  developing 
leucopenia,  a  positive  WidaL  serum  test  and  the 
necessary  bacteriological  examination  of  the 
blood.  It  is  my  opinion  that  a  stubborn,  con- 
spicuous, severe  headache  devoid  of  definite 
signs  of  infection  should  always  remind  us  of 
a  possible  underlying  typhoid  condition. 

We  find  these  mild  cases  among  the  persons 
who  have  been  vaccinated  with  typhoid  serum. 
But  the  vaccination  itself  is  often  enough  con- 
nected with  fever  during  the  first  week,  articular 
pains,  lassitude,  slight  enlargement  of  the  spleen, 
leucopenia,  sometimes  a  light  attack  of  bron- 
chitis and  very  often  severe  pains  in  the  head. 

What  has  been  said  of  typhoid  refers  in  the 


556  GENERALIZED   PAIN 

same  measure  to  paratyphoid,  in  fact  to  every 
kind  of  septic  infection  in  the  widest  sense  of 
the  term.  Every  disease  kindred  to  typhoid  is 
accompanied  by  headache.  Mild  forms  of  chronic 
sepsis  so  frequently  met  with  in  chronic  infec- 
tions of  the  tonsils  or  other  organs  of  the  oral 
cavities  belong  here.  Likewise  Malta  fever  and 
miliary  tuberculosis.  In  the  latter  initial  head- 
aches are  frequently  present  even  though  the 
meninges  do  not  participate  in  any  way  in  the 
tuberculous  process.  Epizootic  and  malignant 
pustule  must  be  mentioned  in  this  place.  In 
epizootic  the  headache  is  generally  localized  in 
the  lateral  region  of  the  cranium.  Anthrax  may 
set  in  with  very  severe  pains  in  the  head  even 
then  when  the  meninges  are  either  not  at  all, 
or  at  any  rate,  but  slightly  implicated  (capillary 
embolism,  hemorrhages). 

Spotted  typhus  —  as  the  World  War  has 
taught  us — may  also  occur  in  the  "walking" 
form,  the  affection  being  centered  in  very  severe 
headaches.  The  sudden  rise  in  the  body  temper- 
ature mainly  due  to  intermittent  chills  (ague), 
inflammation  of  the  conjunctiva  or  of  the  mucous 
membranes  of  the  respiratory  organs  (laryngitis, 
bronchitis)  or  of  the  intestines  (diarrhea),  intu- 
mescence of  liver  or  spleen,  meningeal  irritations 
and  epidermological  conditions  will  demand  an 
early  Weil-Felix  agglutination  test  (which  need 


HEAD  557 

not  be  always  positive)  in  order  to  establish  a 
correct  diagnosis. 

In  malaria  nearly  every  attack  is  accompanied 
by  headache.  In  fact  it  is  in  my  opinion  even 
with  only  a  slight  rise  in  the  temperature  the 
most  salient  feature  of  this  infection  which  in 
its  chronic  form  is  often  the  originating  cause 
of  typical,  periodic,  cranial  neuralgias. 

Syphilis  in  the  secondary  as  well  as  in  the 
tertiary  stage  frequently  gives  rise  to  severe,  at 
times  also  nocturnal,  headaches.  On  account  of 
the  accompanying  articular  pains  and  fever  it 
is  sometimes  mistaken  for  influenza.  I  call  at- 
tention here  to  the  differential  diagnosis  between 
typhoid  and  secondary  syphilis  described  in  the 
section  on  typhoid  fever. 

In  occult  syphilis  the  intermittent  headaches, 
frequently  setting  in  towards  evening  or  during 
the  night  are  an  important  symptom,  no  matter 
whether  they  are  due  to  some  specific  disease  of 
the  bones,  to  meningeal  infiltrations  or  to  some 
vascular  disorder.  Emaciation,  pallor,  sleep- 
lessness, splenic  tumor,  nervous  disturbances 
together  with  the  anamnesis  and  a  positive  Was- 
sermann  reaction  mould  a  safe  diagnosis. 

That  long  list  of  "pseudotyphoid"  diseases  is 
in  every  instance  associated  with  headache,  some- 
times of  an  almost  unbearable  nature,  e.g.,  in 
acute  leucemia. 

Headaches   are   also  the  companions    of   all 


558  GENERALIZED   PAIN 

those  infectious  disorders  which  bear  the  stamp 
of  meningism.  They  are  apparently  due  to 
increased  pressure  of  the  cerebrospinal  fluid. 
Lobar  pneumonia  (simulating  symptomatically 
meningitis)  and  acute  articular  rheumatism  be- 
long to  this  category.  In  the  form  of  cerebral 
rheumatism  the  latter  produces  most  violent 
headaches  and  hyperpyrexia,  followed  by  cere- 
bral excitation  and  coma.  In  lumbar  puncture 
performed  in  this  connection  no  pathological 
conditions  have  as  yet,  so  far  as  I  am  aware, 
been  found. 

In  pulmonary  tuberculosis  headache  seems  to 
be  of  minor  import,  unless  there  are  further 
complications  present,  for  instance  cerebral  con- 
ditions, tubercle,  meningitis,  pachymeningitis, 
sinus  phlebitis  or  caries,  i.e.,  conditions  which  in 
themselves  lead  to  headaches  (heart,  kidney), 
or  violent  fits  of  coughing.  Still  an  initial  pul- 
monary tuberculosis  may  creep  in  with  headache, 
dizziness,  lassitude,  all  of  which  are  symptoms 
of  toxic  origin  and  constitute,  as  it  were,  a  clini- 
cal fact,  when  we  take  into  consideration  that 
frequently  we  are  called  upon  to  differentiate 
between  chlorosis  and  incipient  lobar  or  glandu- 
lar tuberculosis.  On  the  other  hand  these  head- 
aches in  pulmonary  phthisis  are  often  enough 
caused  by  a  chronic  serous  meningitis  of  tuber- 
culo-toxic  origin.  Lumbar  puncture  will  furnish 
the  proof. 


HEAD  559 

In  pellagra  intensive  pain  in  the  head,  but 
variable  in  its  location,  is,  in  close  connection 
with  pains  in  the  back  and  paresthesias  in  the 
extremities,  the  primary  symptom,  showing  how 
the  nervous  system  is  implicated  even  in  the 
earliest  stages  of  the  disease. 

We  now  come  to  the  hereditary  headaches, 
the  familial  or  family  headaches  handed  down  by 
the  parents  or  ancestors  who  suffered  or  still 
suffer  from  headaches  or  migraine  basic  some- 
times in  chronic  alcoholism  or  lead  poisoning, 
to  the  offspring.  They  make  their  appearance 
in  early  childhood  or  at  the  time  of  puberty  and 
are  kindred  to  migraine  (hemicrania).  The 
characteristic  sign  of  these  pains  is  that  they 
generally  occupy  only  one  side  of  the  head;  but 
they  may  be  also  bilateral  in  the  sense  that  they 
move  from  one  side  to  the  other.  In  some  cases 
they  affect  both  sides  simultaneously,  more  pro- 
nounced on  one  side  or  of  equal  severity  in  both. 

They  are  of  a  boring  quality,  chiefly  in  the 
temporal,  more  rarely  in  the  frontal  or  occipital 
region,  spreading  at  times  over  the  whole  hemi- 
sphere, accompanied  also  by  flittering  scotoma 
or  teichopsia  or  facial  disturbances.  In  some 
rare  cases  there  is  paraesthesia  in  the  extremities. 
They  set  in  at  the  early  awakening,  steadily 
increase  in  violence  and  cause  the  sufferer  to 
avoid  all  bodily  motion,  he  feels  ill  and  jaded. 
Hyperesthesia  of  the  visual  and  auditory  organs 


560  GENERALIZED   PAIN 

accompanies  the  pains.  Marked  irritability, 
moodiness,  dislike  of  or  even  unfitness  for  work, 
vasomotoric  manifestations  in  the  face  (pallor, 
flushing),  commonly  go  with  the  attack.  As  a 
rule,  the  patient  recovers  quickly  after  an  attack 
of  vomiting  or  purging. 

Of  importance  for  the  diagnosis  is  the  fact 
that  migraine  predominates  in  the  female  sex 
and  often  sets  in  with  the  menstrual  period.  In 
many  cases  it  disappears  spontaneously  in  the 
climacteric  stage  or,  at  any  rate,  loses  much  of 
its  virulence.  In  pregnancy — mainly  after  the 
second  month — and  during  lactation  it  generally 
ceases  altogether.  Migraine  is  an  inherited  evil 
and  crops  up  in  early  youth.  If  it  makes  its 
appearance  only  at  an  advanced  age — beyond 
the  forties — it  is  not  a  true,  but  rather  a  symp- 
tomatic migraine. 

I  have  mentioned  above  that  migraine  pre- 
vails among  the  gentler  sex  and  often  accom- 
panies the  menstrual  flow.  Valuable  though  this 
knowledge  be,  we  should  not  lay  too  much 
stress  upon  this  fact.  There  are  other  conditions 
which  produce  headaches  and  at  the  very  time 
of  menstruation.  I  refer  to  what  I  have  said 
about  headaches  in  chronic  serous  meningitis  and 
in  abscess  of  the  brain. 

There  are  other  affections  which  show  similar 
symptoms  and  are  often  very  misleading.  The 
uremic  or  urotoxic  headache  is  also  onesided, 


HEAD  561 

the  same  as  in  migraine;  it  is  also  accompanied 
by  vomiting  and  has  the  habit  of  starting  in  the 
morning.  Of  course,  when  we  have  unmistak- 
able proof  of  a  kidney  disease  through  urinalysis 
in  cases  where  this  pseudo-migraine  makes  its 
appearance  in  advanced  age  only,  the  diagnosis 
cannot  go  wrong.  But  in  the  abscence  of  albu- 
minuria  mistakes  will  be  made.  A  correct  diag- 
nosis cannot  be  missed  if  the  following  factors 
are  carefully  weighed:  evidence  of  permanent 
polyuria  (this  may  also  be  present  in  true  mi- 
graine, but  only  in  a  transient  form),  pollaki- 
uria,  nycturia,  examination  of  the  fundus  oculi, 
accentuation  of  the  second  aorta  tonus,  condition 
of  the  peripheral  arteries,  intensity  of  the  blood- 
pressure,  uremic  habitus,  and  all  the  other  symp- 
toms of  the  so-called  "minor  uremia,"  cramps 
in  the  calves,  Raynaud's  disease,  loss  of  appetite, 
itching  of  the  skin,  thorough  test  of  the  renal 
functions.  This  "uremic"  migraine  occurs  not 
only  in  nephritis  but  in  every  kind  of  renal 
insufficiency;  it  is  preeminently  an  early  symp- 
tom in  all  urinary  intoxications  caused  by  chronic 
congestion  in  the  urinary  tract,  e.g.,  in  strictures. 
Exogenous  toxins  may  occasion  recurrent  uni- 
lateral headaches  strongly  resembling  migraine, 
chiefly  chronic  nicotinism.  The  diagnosis  should 
offer  no  difficulties  when  proper  attention  is  paid 
to  the  other  symptoms:  cardiac  disorders  (palpi- 
tation, arhythmia,  anginose  troubles),  disturb- 


562  GENERALIZED   PAIN 

ances  in  the  visual  organs  (impaired  visual  acuity 
with  central  scotoma  for  red  or  green,  tobacco 
amblyopia,  retrobulbar  neuritis),  brown  discol- 
oration of  the  teeth  and  fingers  (cigarettes), 
chronic  laryngeal,  pharyngeal,  bronchial  catarrh, 
disturbances  of  the  nervous  system  (generalized 
and  neuritic). 

Chronic  especially  spastic  obstipation  of  toxic 
origin  may  also  cause  migraine-like  pains  in  the 
head.  It  is  not  often  confined  to  the  lateral 
region,  however.  But  a  true  migraine  may  often 
enough  go  hand  in  hand  with  headache  in  such 
cases,  and  it  will  be  our  task  to  differentiate 
between  the  two.  This  may  be  the  proper  place 
to  point  again  to  the  fact  that  a  genuine  mi- 
graine is  sometimes  eased,  if  not  entirely  stopped, 
by  therapeutic  means  such  as  purging,  or  scour- 
ing. The  differential  diagnosis  should  not  meet 
with  obstacles  when  we  keep  before  us  the  her- 
editary and  familial  moment,  the  concomitant 
symptoms  (vomiting,  hyperesthesia),  the  matu- 
tinal or  nocturnal  beginning  of  the  attack,  and 
the  duty  of  adopting  therapeutic  measures  for 
relieving  the  headache  due  to  chronic  obstipation. 

Neither  must  we  neglect  to  remember  that 
such  headaches  might  be  traced  to  intestinal 
parasites.  Hence  the  necessity  of  proper  exam- 
ination of  the  stools. 

Nervous  gastroxynsis  (Rossbach)  in  connec- 
tion with  migraine  has  already  been  mentioned. 


HEAD  563 

Pains  in  the  frontal  sinus,  in  the  nasal  cavities 
and  toothache  belong  here  also.  Sometimes  even 
a  casual  examination  will  determine  the  differen- 
tial diagnosis  between  these  aches  and  migraine 
in  many  cases.  The  absence  of  visual  symptoms, 
of  vomiting  and  of  hereditary  idiosyncrasies,  the 
fact  that  migraine  will  persist  sometimes  through 
weeks  or  crop  up  only  at  intervals  as  isolated 
attacks,  should  make  the  diagnosis  obvious  irre- 
spective of  local  conditions.  Similar  observa- 
tions may  also  be  made  in  affections  of  the  nasal 
organs  especially  in  women  during  the  menstrual 
period.  But  in  these  cases  the  seat  of  the  pain 
is  rather  in  the  root  of  the  nose  or  in  the  eye. 

To  misjudge  a  neuralgia  of  the  trigeminus  or 
of  the  occipitalis  for  a  migraine  seems  to  me 
well  nigh  impossible.  The  very  fact  that  in  this 
case  the  typical  pressure  points  are  present,  but 
never  vomiting,  should  guarantee  a  correct  diag- 
nosis. 

Unilateral  headaches,  perhaps  with  giddiness 
and  nausea  and  a  solitary  or  repeated  attack  of 
vomiting  should  always  point  to  the  existence  of 
an  arteriosclerosis  in  the  plexus  of  the  cerebral 
arteries.  If  the  headaches  are  of  an  intermittent 
character  we  may  give  thought  to  an  intermittent 
angiospasm  of  the  arteries  which  have  already 
been  impaired  by  arteriosclerosis.  If  the  pains 
continue  for  days  or  weeks  they  are  a  sign  of 
thrombosis  in  a  cerebral  artery.  Visual  and 


564  GENERALIZED   PAIN 

skin  reflexes  (exacerbation  of  the  former,  ab- 
sence of  the  latter),  the  Babinski  toe  pheno- 
menon, hypersensitiveness  of  the  sensory  and 
motoric  faculties  (paresthesias,  pains),  muscular 
contractions  in  the  extremities  contralateral  to 
the  lesion,  or  manifestations  of  minor  defects 
should  be  auxiliaries  of  the  diagnosis.  In  many 
cases  this  can  be  made  merely  on  the  ground 
of  the  age  of  the  patient,  symptoms  of  arterio- 
sclerosis of  the  cerebral  or  other  arterial  regions. 
Sufferers  from  migraine  may  also  become  the 
victims  of  cerebral  arteriosclerosis  at  a  later  time 
in  life.  The  anamnesis,  the  periodical  succession 
of  the  manifestations,  the  point  that  migraine, 
with  exceptions,  of  course,  generally  lapses  into 
desuetude  with  the  advent  of  the  climacterium, 
i.e.,  to  put  it  rudely,  the  season  for  cerebral 
arteriosclerosis,  aught  without  default  invariably 
clear  up  the  situation. 

An  acute  glaucoma  has  often  enough  been 
mistaken  for  migraine.  Both  have  in  common 
unilateral  recurrent  headache,  pain  in  the  eye 
which  lies  in  front  of  the  headache,  subjective 
disturbances  in  the  visual  apparatus,  and  like- 
wise vomiting.  If  in  the  bargain  the  patient 
suffers  from  migraine  already,  the  error  becomes 
still  more  excusable.  Only  a  thorough  test  of 
the  bulbar  tension,  in  other  words  a  careful 
ophthalmoscopic  examination  will  remove  any 
doubts  that  may  exist. 


HEAD  565 

Pronounced  unilateral  headache  with  vomiting 
and  strongly  resembling  migraine  occurs  also  in 
another  combination;  I  refer  to  the  so-called 
periodic  oculomotor  paralysis.  It  makes  its  ap- 
pearance either  before  or  simultaneously  with 
the  attack.  In  its  pre-  or  coexistence  and  in 
the  anamnesis  (appearance  in  childhood  or  early 
youth)  we  may  find  the  key  to  the  diagnosis. 

Myalgia  capitis  is  at  times  erroneously  taken 
for  migraine  because  it  also  is  associated  with 
severe  headaches  although  they  generally  de- 
velop on  both  sides  of  the  head.  But  the  fact 
that  the  pains  in  myalgia  are  continuous,  though 
at  times  of  a  milder  character,  should  be  the 
determining  element,  especially  if  the  symptoms 
typical  for  each  of  these  two  affections  are  care- 
fully considered. 

If  in  migraine  a  so-called  status  Tiemicranicus 
results  from  cumulative  attacks,  the  differential 
diagnosis  will  be  surrounded  by  difficulties.  One 
attack  follows  the  other  with  intervals  of  a  pos- 
sible restful  night.  Sometimes  the  patient  is 
distracted  by  continuous  pain  for  six  or  seven 
days  on  a  stretch.  Visual  symptoms  and  vomit- 
ing are  not  always  present.  In  such  cases  the 
diagnosis  must  rest  entirely  on  the  anamnesis. 

When  the  diagnosis  of  migraine  has  been 
firmly  established  it  will  yet  be  necessary  to 
remember,  that  not  all  cases  of  a  true  migraine 
are  a  protopathic  vasomotoric  neurosis.  They 


566  GENERALIZED   PAIN 

may  be  of  a  secondary  nature,  especially  when 
the  first  attacks  arrive  only  at  an  advanced  age 
and  bear  no  signs  of  familial  or  hereditary  origin. 
A  migraine  accompanied  by  visual  symptoms, 
migraine  ophihalmique,  a  combination  of  uni- 
lateral headaches  and  a  clouding  of  the  visual 
field,  should  always  remind  us  of  a  localized 
affection  of  the  brain,  chiefly  of  the  hypophysis 
or  the  occipital  cranial  fossa,  a  cerebral  tumor, 
also  of  acute  or  chronic  serous  meningitis,  aneu- 
rysm  of  the  cerebral  arteries,  progressive  par- 
alysis, taboparalysis,  syphilis  of  the  brain,  mul- 
tiple insular  sclerosis  or  tuberculous  headache. 
The  ophthalmic  form  offers  difficulties  before 
the  typical  symptoms  have  been  fully  developed. 

Useful  points  to  remember  are:  in  migraine 
vomiting  brings  relief,  often  the  end  of  the 
attack;  in  tumor,  resp.  meningitis  the  patient 
feels  weak,  has  a  jaded  look  after  vomiting.  In 
migraine  absolute  rest,  the  exclusion  of  light  and 
noise  have  a  soothing  effect;  but  not  in  tumor, 
at  least  not  to  any  extent.  The  tumor  patient 
is  indifferent  to  his  surroundings,  mentally  be- 
numbed, but  not  so  in  migraine.  But  migraine 
may  also  in  due  time  develop  a  cerebral  lesion. 

In  pyrgocephalus  we  frequently  find  mi- 
grainic  conditions.  The  characteristic  formation 
of  the  head,  the  bulbar  protusion,  atrophy  of 
the  optic  nerve,  the  Roentgenogram  are  typical 
enough  for  diagnostic  purposes. 


HEAD  567 

Epileptic  migraine  is  not  always  so  easily 
recognized.  An  epileptic  coma  may  very 
strongly  resemble  migraine.  Even  an  atypical 
attack  of  epilepsy  may  have  many  symptoms  in 
common  with  a  migraine  such  as  headache,  par- 
esthesia  in  the  arms  and  optic  disturbances.  But 
we  shall  find  a  strong  hold  in  the  contemplation 
of  the  hereditary  conditions,  of  the  convulsive 
muscular  reactions,  the  rotation  of  rudimentary 
attacks  and  genuine  epileptic  fits,  and  also  occa- 
sional enuresis. 

A  deuteropathic  status  hemicranicus  may  also 
be  observed  in  another  form  of  neurosis,  I  mean 
cyclothymia.  If  depressing  moodiness  is  strongly 
marked,  the  diagnosis  will  be  easy.  But  when, 
as  will  happen,  the  migrainic  attacks  are  asso- 
ciated with  a  scintilating  scotoma  and  other 
somatic  disturbances,  such  as  periodic  sleepless- 
ness, dyspepsia,  diarrhea  and  urticaria,  then  only 
a  competent  psychanalysis  will  uncover  the  true 
state  of  affairs. 

Quincke's  edema  ( hy drops  hypostrophos)  may 
likewise  lead  to  a  secondary  migraine  coupled 
even  with  external  opthalmoplegia  (abducens 
oculomotorius).  Such  cases  are  so  obvious,  how- 
ever, that  they  leave  no  room  for  doubt. 

The  same  may  be  said  of  erythromelalgia. 

Uratic  migraine  has  been  mentioned  by  some 
French  authors  in  this  connection,  not  only  in 
the  sense  that  migraine  may  be  basic  in  gout, 


568  GENERALIZED   PAIN 

but  also  that  an  acute  attack  of  gout  might  be 
substituted  by  an  attack  of  migraine.  I  have 
never  been  convinced  of  this.  Yet  it  strikes  me 
that  migraine,  not  unlike  neurasthenia,  finds  in 
gouty  conditions  rather  a  fertile  ground.  Quite 
recently  the  opinion  of  our  French  colleagues 
has  been  maintained  by  several  specialists  who 
are  well-recognized  authorities  on  this  subject. 

Polycythemia  rubra  may  also  give  rise  to 
migraine-like  headaches. 

The  same  may  be  said  of  essential  arterial 
hypertension. 

Hysteria  may  also  simulate  migraine.  Even 
typical  hysterical  stigmata  do  not  definitely 
exclude  a  state  of  genuine  migraine,  for  both 
diseases  may  very  well  co-exist.  The  presence 
of  a  scintilating  scotoma  and  hereditary  taint 
should  furnish  the  final  proof. 

From  what  I  have  placed  before  my  readers 
it  will  be  clear  that  a  definite  localization  of 
headache  cannot  be  reduced  to  a  definite  genesis. 
But  the  following  auxiliary  deductions  may  be 
garnered  from  the  perusal  of  the  foregoing 
pages:  pain  in  the  occipital  region  points  to 
induration  headache  as  the  originating  cause  or 
to  occipital  migraine  or  uremic  cephalea  or  an 
affection  of  the  heart  or  the  fauces.  A  circum- 
scribed headache  in  the  frontal  region  may  arise 
from  an  optic  disorder,  from  the  nose  or  from 
the  frontal  sinus.  Strictly  defined  pain  in  the 


HEAD  569 

vertex  directs  our  attention  to  hysterical  etiol- 
ogy. Benumbing  pain  in  the  vertex  leads  to 
ethmoiditis  and  pain  in  the  temporal  region 
around  the  ear  to  otological  conditions  or  affec- 
tions of  the  teeth  as  the  causal  factors.  For  the 
local  diagnosis  of  a  cerebral  tumor  headache  is 
one  of  the  strongest  indications,  especially  when 
it  is  accompanied  by  the  sensation  of  humming 
in  the  cranium  and  tympanitic  percussion  sound 
in  this  region  with  bruit  de  pot  fele. 


INDEX 


Abdomen,   diseases  of,  arthral- 
gia  in,  497 

pendulous,  sacral  pain,  76 
Abdominal     diseases,     pain     in 

shoulder,  123,  134 
Abdominal  muscles,  diseases  of, 

pain  in  chest,  216 
Abdominal  tumor,  pain  in  ex- 
tremities, lancinating,  362 

sacral  pain,  76 

Abscess,  peripleuritic,  pains  in 
chest,  197 

subcutaneous,  or  empyema 
necessitatis,  196 

subcutaneous,  or  perforation 
of  a  pulmonary  cavern 
through  the  pectoral  wall, 
197 

bubpectoral,  pains  in  chest, 
209 

eubphrenic,  or  pleurodynia, 
236 

subphrenic,  pains  in  shoulder, 

116 
Achillodynia  or  dysbasia,  306 

pains  in  extremities,  306,  342 
Acroasphyxia,  chronic  hypertro- 
phic,  paresthesia  in  extrem- 
ities, 272 
Acromegaly,  headache,  518 

or  cranium  progenium,  440 

or  cretinism,  441 

or  elephantiasis,  442 

or  giantism,  440 

or  habitus  scrophulosus,  442 

or  myxedema,  441 

or  neurasthenia,  443 

or  osteoarthropathic  hyper- 
trophiante  pneumique,  423 

or  pachydermia,  442 

or  Paget's  ostitis,  420 

or  pseudoacromegaly  in  preg- 
nancy, 440 

or  syringomyelia,  440 

671 


Acromegaly,      or      vasomotoric 

elongation  of  fingers,  441 
pain  in  back,  155 
pain  in  bones,  405 
pain  in  extremities,  lancinat- 
ing, 352 
paresthesia     in     extremities, 

286 

Acromegaloidism,  442 
Acroparesthesia,     pain    in    ex- 
tremities, 266 
Actinomycosis,    pain    in   bones, 

417 

prevertebral,   pain   in   shoul- 
ders, 128 
Addison'a      disease,      articular 

pain,  491 
headache,  535 
muscular  pain,  369 
pains  in  extremities,  261,  346 
paresthesia     in     extremities, 

261,  286 

retrosternal  pain,  230 
Adipositas  dolorosa,  arthralgia 

in,  500 

pain  in  extremities,  281 
Adrenals,   diseases  of,  pain   in 

sacrum,  92 
diseases  of,  retrosternal  pain, 

228 
insufficiency  of,  cardiac  pain, 

4 

insufficiency  of,  headache,  535 
Akinesia    algera,    or    dysbasia, 

303 

pain  in  extremities,  303 
Albuminuria,     orthotic,     head- 
ache, 536 
orthotic,    pain    in    shoulder, 

535 

Alcaptonuria,  sacral  pain,  92 
Alcoholism.    See  Poisoning. 
Aleucemia,  pain  in  bones,  426 
Anasarea,  pain  in  extremities, 
259 


572 


INDEX 


Anemia,   hemolytic,   percussion 
sensitiveness  in  bones,  429 

hemorrhagic,  acute  pain  in 
heart,  6 

infantum  pseudoleucemica, 
Jaksch,  articular  pain,  471 

infantum  pseudoleucemica, 
Jaksch,  percussion  sensi- 
tiveness in  bones,  429 

pain  in  shoulder,  126 

paresth'esia  in  extremities, 
267 

pernicious,  pain  in  bones,  426 

pernicious,  paresthesia  in  ex- 
tremities, 279 

pernicious,    percussion    sensi- 
tiveness in  bones,  426 
Aneurysm  of  the  heart,  cardiac 

pain,  5 
Angina   Ludovici,   pain   in   the 

neck,  175 

Angina  pectoris  and  aneurysm 
of  the  aorta,  70 

and  fever,  71 

and  neuritis  of  the  aortic 
plexus,  68 

and  dyspnea,  69 

dead  fingers,  296 

dyspeptogenous,  44 

girdle  pain,  207 

girdle  pains  in  neck,  186 

headache,  549 

or  gastralgia,  27 

or  intercostal  neuralgia,  62 

or  neuritis  of  the  phrenic 
nerve,  63 

or  occipital  neuralgia,  69 
Angina    pectoris,    or    pseudoan- 
gina  pectoris  in  carcinoma 
of  the  pancreas,  57 

in  carcinoma  of  the  stomach, 
58 

or  in  carclialgia,  67 

in  cholelithiasis  (hepatic 
colic),  53 

in  dilatation  of  the  esopha- 
gus, 65 

in  esophagalpria,  67 

in  embolism  of  the  pulmonary 
artery,  48 

in  esophagospasms,  65 

in  fibrous  mediastinitis,  50 

in  gastric  diseases,  58 


Angina  pectoris,  in  gastric  vol- 

voulus,  51 

in  intestinal  diseases,  60 
in  membranaceous  colitis,  61 
in  mediastinal  tumors,  50 
in    neuritis     of     the    vagus 

nerve,  64 
in     neurosis     of     the     vagus 

nerve,  64 

in  pancreatitis  (necrosis),  57 
in  peracute  congestion  of  the 

liver,  55 

in    perforation    of    the    peri- 
cardium, 51 
in  perigastritis,  51 
in  pulmonary  stenosis,  48 
in  sclerosis  of  the  pulmonary 

artery,  48 

in  pylorus  stenosis  colic,  60 
in  syphilis  of  the  liver,  54 
in  thrombosis  of  the  pulmon- 
ary artery,  51 
in  ulcus  ventriculi,  51,  59 
in  thrombosis  of  the  superior 

vena  cava,  51 

in  tumors  of  the  heart,  50 
or  thoracico  brachial  neural- 
gia, 62 

or  trigeminal  neuralgia,  69 
pain  in  chest,  203 
pain  in  extremities,  297 
pains   in   region   of  ensiform 

appendix,  219 
pains  in   shoulder  ,112,    137, 

140,  142 

pain  in  throat,  181 
paresthesia    in    the    extremi- 
ties, 290 
paresthesia     in     extremities, 

271 

retrosternal  pain,  221 
(stenocardia),  26 
vasomotoria,  41 
Anginose  state,  71 
or  gastric  crises,  72 
or  pericarditis,  71 
Anglophobia,  38 
Angina    tonsillaris.      See    Ton- 
sillitis. 
Anthrax,  headache,  556 

pain  in  sacrum,  80 
Antrum  of  Hiehmore,  diseases 
of,  headache,  538 


INDEX 


573 


Aorta  abdominal,  aneurysm  of. 

sacral  pain,  98 

Aorta,    insufficiency    of,    head- 
ache, 527 
pectoral,    aneurysm    of,    and 

angina  pectoris,  70 
aneurysm  of,  cardiac  pain,  12 
aneurysm  of,  girdle  pain,  206 
aneurysm       of,      lancinating 

pains  in  extremities,  352 
aneurysm    of,    pain    in    the 

chest,  199,  203,  221,  244 
aneurysm  of,  pain  in  the  ex- 
tremities, 332 
aneurysm    of,    pain    in    the 

shoulder,  114,  122,  134,  142 
diseases  of,  retrosternal  pain, 

220 
embolism    or    thrombosis    of, 

pain  in  extremities,  312 
perforation  of,  pains  in  chest, 

251 
perforation     of,     retrosternal 

pain,  248 

rupture  of,  cardiac  pain,  251 
rupture    of,    pains    in    back, 

114,  163 
rupture    of,    pains    in    chest, 

251 
rupture  of,  pain  in  shoulder, 

138 
sclerosis   of,  angina   pectoris 

in,  28 
sclerosis   of,    anginoid    pains, 

14 
sclerosis   of,   pains   in   chest, 

244 
sclerosis  of,  pain  in  shoulder, 

135,  142 
Stenosis   of,    angina    pectoris 

in,  27 
syphilis    of,    angina    pectoris 

in,  28 
syphilis    of,    anginoid    pains, 

14 
Aorta,    thoracic,    aneurysm    of, 

pains  in  the  back,  163 
pectoral,  sclerosis  of,  pain  in 

back,  163 
syphilis    of,    pains    in    back, 

163 


Aortalgia,  cardiac  pains,  10 
pains   in   region  of   ensiform 

process,  219 
pains  in  shoulder,  112 
Aortitis,  angina  pectoris  in,  27 
cardiac  pain,  22 
girdle  sense,  206 
pain  in  back,  163 
Apoplexy,      meningeal,      sacral 

pain,  90 
Appendicitis,  pain  in  shoulder, 

140,   144 

Arteriosclerosis,  cardiac  pain,  9 
dead  fingers,  297 
pain  in  extremities,  307 
pain  in  neck,  180 
paresthesia     in     extremities, 
267,  291 

Arteritis,   pain   in   extremities, 
311 

paresthesia     in     extremities, 

291 

Arteritis.    See  Brain. 
Artery,  anonyma,  aneurysm  of, 
cardiac  pain,  12 

anonyma,  aneurysm  of,  pain 
in  chest,  221 

anonyma,  aneurysm  of,  pain 
in  shoulder,  142 

celiac,  diseases  of,  pain  in 
back,  168 

cerebral.    See  Brain. 

constriction  of  an,  headache, 
528 

constriction  of  an,  pains  in 
extremities,  315 

constriction  of  an,  paresthe- 
sia in  extremity,  292 

coronary  of  the  heart,  embo- 
lism, thrombosis,  angina 
pectoris  in,  29 

coronary  of  the  heart,  scle- 
rosis of,  angina  pectoris  in, 
28,  35 

coronary  of  the  heart,  scle- 
rosis of,  anginoid  pains,  14 

coronary  of  the  heart,  scle- 
rosis of,  pains  in  shoulder, 
139 

coronary  of  heart,  syphilis  of, 
anginoid  pains,  14 


574 


INDEX 


Artery,  cutaneous,  embolism  of, 

pain  in  extremities,  266 
cutaneous,     thrombosis      of, 

pain  in  extremities,  264 
embolism    or    thrombosis    of 

an,    pains    in    extremities, 

312 
intercostal,  sclerosis  of,  pains 

in  chest,  244 
mammary,  sclerosis  of,  pains 

in  chest,  202 
pulmonary,       embolism       of, 

pseudoangina    pectoris    in, 

49 
pulmonary,     retrosternal 

pains,  247 

pulmonary,  sclerosis  of,  pseu- 
doangina pectoris  in,  48 
pulmonary,  stenosis  of,  pseu- 
doangina  pectoris  in,  49 
pulmonary,     thrombosis     of, 

pseudoangina    pectoris    in, 

50 
Arthralgia  in  abnormal  growth, 

499 

in  adipositas  dolorosa,  500 
in  articular  neuralgia,  496 
in  chronic  constipation,  497 
in  climacterium,  499 
in  epilepsy,  495 
in  gout,  498 
in  hysteria,  495 
in  infectious  diseases,  600 
in    insufficiency    of    the    thy- 

reoid  glands,  500 
in  lead  poisoning,  498 
in  malaria,  498 
in  multiple  sclerosis,  495 
in  neurasthenia,  495 
in  pelvic  and  abdominal  dis- 
eases, 497 

in  rachitis  tarda,  498 
in  tabes,  497 
in  uremia,  499 
syphilitic,  articular  pain,  451, 

454 
Arthritis.      See   also   Articular 

Rheumatism  and  Gout. 
Arthritis   deformans,    articular 

pains,  483 
or  arthropathy,  505 
or  neuralgia  (neuritis),  483 


Arthritis  deformans,  or  oateo- 
arthropatie  hypertrophi- 
ante,  504 

or  osteomalacia,  443 

or    osteomalacia     (osteoporo- 
sis), 505 

or  syringomyelia,  494 
Arthritis,  acute,  or  osteomyeli- 
tis, 470 

enteric,  articular  pain,  458 

gonorrhoic  and  typhoid,  464 

gonorrhoic,     articular     pain, 
448 

gonorrhoic  or  syphilitic,  454 

mon-,  or  osteomyelitis,  507 

mon-,  pneumococcic,  articular 
pain,  475 

mon-,  post  traumatic,  articu- 
lar pain,  475 

mon-,     rheumatic,     articular 
pain,  475 

mon ,  rheumatic,  gonorrhoic, 
articular  pain,  475 

mon-,     syphilitic,      articular 
pain,  475 

septic,  articular  pain,  449 

septic,    mitigated,    articular 
pain,  474 

syphilitic,  articular  pain,  454, 
478 

syphilitic,     glandular     swell- 
ings, 454 

syphilitic  or  gonorrhoic,  454 

tuberculous,    articular    pain, 

475 

Arthropathy,  articular  pain, 
477,  493 

in    prosiasis,    articular    pain, 

490 
Arthrogryposis,  articular  pain, 

472 

Articular  rheumatism,  acute, 
and  gout,  489 

and  typhoid,  464 

gonorrh.  and  typhoid,  464 

headache,  558 

mitigated,  474 

muscular  pains,  376 

pain  in  bones,  419 

pain  in  extremities,  340 

pain  in  sacrum,  77 

or  neuritis,  472 

or  poliomyelitis,  473 


INDEX 


575 


Articular  rheumatism,  swelling 

of  lymphatic  glands,  455 
Articular  rheumatism,  chronic, 

articular  pain,  469,  478 
and  gout,  487 
in  climacterium,  503 
nodose,  503 

or  paralysis  agitans,  503 
or  sclerodermia,  504 
or  syringomelia,  494 
paresthesia     in     extremities, 

267 

Articular  rheumatism,  syphili- 
tic, articular  pains,  491 
tuberculous,   articular  pains, 

452,  491 
Articular  rheumatism.  See  also 

Arthritis,  Rheumatism. 
Articulation,  sacro-ileac,  arthri- 
tis of,  or  of  the  hip  joint, 
508 
arthritis  of,  or  osteomyelitis, 

508 

diseases  of,  sacral  pain,  85 
Aseitee,  sacral  pain,  76 
Asthma,     bronchial,     pain     in 

back,  168 

bronchial,  feeling  of  constric- 
tion in  the  neck,  188 
bronchial,   pain   in   shoulder, 

132 
hay-,  feeling  of   constriction 

in  throat,  1"88 

Atropin  poisoning,  pain  in  ex- 
tremities, 385 
Axilla,  pain  in,  360 
Autointoxication.      See     Intes- 
tines. 


Barlow's  disease,  pains  in  bones, 

425 
Basedow's  disease,  angina  pec- 

toris  in,  35 
articular  pain,  472 
cardiac  pain,  anginoid,  16 
muscular  pain,  370 
pains  in  bones,  429 
paresthesia     in     extremities, 

286 
percussion     sensitiveness     in 

bones,  429 
retrosternal  pain,  230 


Bedsores,   pain   in  extremities, 

260 

Blood,    diseases   of,    percussion 
sensitiveness  in  bones,  429 
Blood  pressure.    See  Hyperten- 
sion. 
Bones,     atrophy     of,     Sudek's, 

pain  in  bones,  400 
brittleness  of,  432 
diseases    of,    after    diarrhea, 

pain  in  bones,  424 
hyperostitis    of,    or    Paget's 

ostitis,  420 
hyperostoeis      of,      headache, 

nocturnal,  514 
hyperostosis      of,      pain      in 

bones,  403 

Bones,  neoplasms  of,  or  arthri- 
tis deformans,  505 
or   chronic   syphilitic   articu- 
lar rheumatism,  506 
or  chronic  tuberculous  articu- 
lar rheumatism,  491 
or  myeloma,  412 
or  Paget's  ostitis,  420 
pain  in  bones,  401,  406,  413 
Bonee,    pains    in,    lancinating, 

429 

pains  in,  nocturnal,  398 
percussion    sensitiveness    in, 

429 

spontaneous  fracture  of,  ar- 
ticular pain,  477 
swellings  in,  433 
Botulism,    feeling   of    constric- 
tion in  throat,  188 
Bradycardia,     angina    pectoris 

in,  37 
Brain,  abscess  of,  headache,  518 

anemia  of,  headache,  527 
Brain,  arteries  of,  aneurysm  of, 

headache,  nocturnal,  514 
aneurysm  of,  migraine  in,  566 
Brain,  arteries  of,  sclerosis  of, 

and  neurasthenia,  523 
cardiac  pain,  anginoid,  16 
headache,  523,  532 
headache  in  or  migraine,  563 
muscular  pain,  389 
or  neurasthenia,  523 
paresthesia     in     extremities, 
281 


576 


INDEX 


Brain,  arteries  of,  syphilis  of, 

headache,  525 

sypuilis  of,  pain  in  extremi- 
ties, 283 

thrombosfs  of,  headache,  524 

thrombosis    (embolus)    of, 

paresthesia  in  extremities, 

283 

Brain,     diseases     of,     articular 

pain,  493 
migraine  in,  565 
muscular  spasms,  tetanic,  388 
pain  in  back,  155 
pain  in  shoulders,  138 
paresthesia     in     extremities, 

281 

trismus  in,  348,  384 
Brain,  fatty  embolism  of,  mus- 
cular  spasms,  tetanic,  390 
hemorrhage  of,  headache,  524 
hyperemia    (acute,   passive), 

headache,  528 
increased    pressure    in,    and 

headache,  530 
sinus  phlebitis  of,  headache, 

530 

syphilis  of,  migraine  in,  566 
tumors  of,  headache,  518 
tumors  of,  migraine  in,  549 
tumors  of,  muscular  spasms, 

tetanic,  390 

tumors  of,   pain  in  extremi- 
ties, lancinating,  353 
Breast,    wall    of,    diseases    of, 

stitches  in  side,  247 
Bronchial    carcinoma,    pain    in 

back,  164 

pain  in  shoulder,  131 
Bronchiectasy,    articular    pain, 

472 
Bronchi,  foreign  bodies  in,  pain 

in  chest,  246 
Bronchitis,    pain    in    shoulder, 

132 
Broncholithiasis,       retrosternal 

pain,  226 
Bronchosarcoma,       retrosternal 

pains,  224 

Bmck's  disease,  pain  in  bones, 
425 


Bursitis   subdeltoidea,   pain   in 

shoulder,  111 
subscapular,  pain  in  shoulder, 

121 
Buttocks,  pains  in,  103 

C 

Cachexia,   pain  in  extremities, 

279 
percussion     sensitiveness     in 

bones,  431 

Caison  disease,  pain  in  extremi- 
ties, 288 

pains  in  extremities,   lancin- 
ating, 351 

Calcaneous    spur,    pain    in    ex- 
tremities, 343 
Calves,  cramps  in,  355 
Cardiac  pain,  anginoid  or  neu- 
rasthenic, 15 
Cardialgia,    pseudoangina    pec- 

toris  in,  67 

Cardioptosis,  cardiac  pain,  8 
Cervical    muscles,    diseases    of, 

pains  in  neck,  169 
Cellulitis  retroperitonealis,  pain 

in  sacrum,  94 
Chest,  pressure,  oppression   in, 

255 

Chiragra,  pains  in  joints,  488 
Chloroma,  headache,  514 
pains  in  bones,  426 
pains  in  nape  of  neck,  193 
swelling  in  bones,  434 
Chlorosis,  dead  fingers  in,  296 
pain  in  shoulders,  126 
paresthesia  in  extremities,  267 
percussion     sensitiveness     in 

bones,  429 

Cholecystitis,  pain  in  back,  166 
pain  in  chest,  255 
headache,  548 

Cholelithiasis,  headache,  547 
pain  in  back,  166 
pain  in  chest,  255 
pain  in  sacrum,  93 
pseudoangina  pectoris  in,  53 
retrosternal  pain  in,  230 
Cholera,  muscular  pain,  377 
Chorea,  paresthesia  in  extremi- 
ties, 286 

Climacterium,     arthralgia     in, 
499 


INDEX 


577 


Climacterium,    articular    rheu- 
matism, chronic  in,  603 
headache,  531 
pain  in  bones,  427 
pain  in  chest,  202 
pain  in  sacrum,  99 
paresthesia     in     extremities, 

287 
Coccygodynia.       See     Pain     in 

Nates. 

Cold.     See  Arthritis. 
Coitus  interruptus,  pain  in  sac- 
rum, 101 

Colitis    membranacea,    pseudo- 
angina  pectoris  in,  61 
Colitis,    ulcerous,    articular 

pains,  458 
Colon,    carcinoma    of,    pain    in 

sacrum,  101 
Comptodactylia,  503 
Constipation,  headache,  542 
headache  in,  or  migraine,"  560 
pain  in  extremities,  332 
pleurodynia  in,  237 
Cramps,    pianoplayers',    pares- 

thesia  in  extremities,  271 
writers',    paresthesia    in    ex- 
tremities, 271 
Cranium    progeneum    or    acro- 

megaly,  440 

myeloma  of,  headache,  514 
neoplasms  of,  headache,  noc- 
turnal, 514 

Cretinism  or  acromegaly,  441 
Crises  gastriques.     See  Gastric 

Crises. 

Cyclothymia,  migraine  in,  567 
Cysticercus,  muscular  pain,  374 


Decubitus,  pain  in  sacrum,  88 

Degeneration,      adiposo-genital, 
pain  in  bones.  425 

Dementia  precox,  92 
headache,  525 
pain  in  back,  159 
pain  in  extremities,  261 
paresthesia     in     extremities, 
261 

Dengue,  articular  pain,  460 
pain  in  sacrum,  82 


Dercum's   disease,   pain   in   ex- 
tremities, 261 

see  Adipositas  dolorosa. 
Dermatomyositis,   muscular 
pain,  371 

or  phebitis,  375 

Diabetes   mellitus,   angina  pec- 
toris in,  33 

headache,  541 

headache,  nocturnal,  514 

muscular  pains,  369 

pain  in  extremities,  332 

pain  in  extremities,  lancinat- 
ing, 351 

paresthesia     in     extremities, 

267 

Diaphragm,    cramps    in,    girdle 
feeling  in,  206 

diseases  of,  pain  in  chest,  247, 
256 

diseases  of,  pain  in  region  of 
ensiform  cartilage,  218 

diseases    of,    pleurodynia    in, 
237,  247 

elevation  of,  cardiac  pains,  9 

elevation  of,  cardiac  pain,  an- 
ginoid,  19 

eventration  of,  cardiac  pains, 
12 

eventration  of,  pains  in  chest, 
252 

eventration  of,  pains  in  shoul- 
der, 117 

foreign    bodies    in,    pain    in 
shoulder,  117 

hemorrhage   below   the,   pain 
in  chest,  252 

hernia  of,  cardiac  pains,  12 

hernia   of,  pain  in  shoulder, 
117 

hernia  of,  or  pneumothorax, 
252 

hernia  of,  pains  in  chest,  247, 
252 

hernia  of,  pleurodynia  of,  247 

paresis,    acute,    of,    pain    in 

chest,  253 
Diaphragmatitis,  pain  in  chest, 

208 

Digitus  semi-mortuus,  296 
Diphtheria,  articular  pains,  450 

muscular  spasms,  tetanic,  392 

trismus  in,  384 


578 


INDEX 


Dorsal     muscles,     diseases     of, 

pain  in  back,  159 
diseases  of,  pain  in  shoulder, 

126 

Drumstick  fingers,  436 
Duodenum,  carcinoma  of,  pains 

in  back,  168 

rupture  of,  pains  in  back,  168 
ulcer  of,  pains  in  back,  168 
ulcer  of,  pain  in  sacrum,  93 
ulcer    of,    retrosternal    pain, 

230 
Dysbasia,   angiosclerotic,   pains 

in  extremities,  298,  344 
see  also  Limping. 
Dysbasia,  or  achillodynia,  306 
or  akinesia  algera,  303 
or  arterio  -  sclerotic  neuritis, 

301 

or  flatfoot,  304 
or  ischias,  301 
or  meralgia,  303 
or  myotonia,  306 
or  neurasthenia,  303 
or  occupational  neurosis,  290 
or  peripheral  neuritis,  301 
or  rupture  of  muscular  fascia, 

306 

or  trichinosis,  307 
spinal,  girdle  sense,  206 
spinal,  or  osteomalacia,  445 
Dysentery,  articular  pains,  458 

pains  m  extremities,  340 
Dyspepsia,  headache,   548 

see  also  Flatulence 
Dysphagia     lusoria,     pain     in 

chest,  227 
Dyspragia  and  angina  pectoris, 

39 

Dyspragia,  intermittent  or  cer- 
vical rib,  309 
intermittent,        muscular 

cramps,  353 

intermittent,  pain  in  extremi- 
ties, 307 

intermittent,  pains  in  shoul- 
der, 111 

intermittent,    see   also  Limp- 
ing. 

Dysbasia,  spinal,  paresthesia  in 
extremities,  279,  290 


E 


Ear,  diseases  of,  headache,  538 
Eclampsia,     muscular     spasms, 

tetanic,  393 
Edema,  Quincke's,  migraine  in, 

567 

Quincke's,  paresthesia  in  ex- 
tremities, 272 

resorption  of,  headache,  541 
see  also  Hydrops. 
Edematous     disease,     muscular 

pain,  381 
Elephantiasis    or     acromegaly, 

442 

Empyema  and  pleurodynia,  242 
Empyema,  interlobar,  pains  in 

shoulders,  144 
interlobar,     pleurodynia     in, 

236 
necessitatis,    pain    in    chest, 

196 

necessitatis  or  perforation  of 
a  pulmonary  cavern  through 
the  wall  of  the  chest,  196 
necessitatis    or    subcutaneous 

abscess,  196 
pain  in  chest,  216 
see  also  Pyothorax. 
Encephalitis,     articular     pains, 

459 

headache,  517 

muscular  cramps,  tetanic,  389 
pain  in  extremities,  332 
trismus  in,  383 

Encephalopathia,  saturnine, 
muscular  spasms,  tetanic, 
389 

Endarteritis.     See  Brain. 
Endocarditis     lenta,     articular 

pains,  450 
Ensiform  process,  pains  in  the 

region  of,  218 
Ehteroptosis,  cardiac  pain,  7 

pain  in  sacrum,  76 
Epilepsy,  arthralgia  in,  495 
cardiac  pain,  anginoid,  17 
headache,  535 

muscular  spasms,  tetanic,  393 
or  migraine,  567 
pain  in  extremities,  268,  346 


INDEX 


579 


Epiphyses,  affection  of,  syphili- 
tic, brittleness  of  bones, 
433 

Ergotism.  See  Poisoning,  ergot. 
Erysipelas,  articular  pain,  458 
headache,  509,  552 
pallidum,  pain  in  extremities, 

264 

pain  in  throat,  173 
trismus  in,  384 
Erysipeloid,  pain  in  joints,  466 

pain  in  extremities,  263 
Erythema     nodosum,     pain    in 

bones,  428 
Erythema     contagiosum,     pain 

in  sacrum,  82 

Erythema  nodosum,  pain  in  ex- 
tremities, 258 
Erythromelalgia,    migraine    in, 

567 

pain  in  back,  161 
pain  in  extremities,  261 
Esophagalgia,         pseudoangina 

pectoris  in,  67 

Esophagitis,  pain  in  neck,  184 
Esophagospasm,     pseudoangina 

pectoris  in,  66 
retrosternal  pain,  227 
Esophagus,  carcinoma  of,  pain 

in  shoulder,  123 
dilatation    of,    pseudoangina 

pectoris  in,  65 

diseases  of,  pain  in  back,  183 
diseases  of,  pain  in  ensiform 

process,  219 
diseases  of,  pain  in  shoulder, 

133 
diseases    of,    pain   in   throat, 

184 
diseases  of,  retrosternal  pain, 

226 
diverticulum     of,     pain     in 

throat,  184 

intermittent  angiosclerotic 
dyspragia  of,  pseudoangina 
in,  68 

perforation   of,   into   the   air 
passages,  retrosternal  pain, 
223,  226,  248 
ulcer    of,    retrosternal    pain, 

227 

Eventration,  diaphragmatic. 
See  Diaphragm. 


Extremity,  defective  circulation 
in,  paresthesia  in  extremi- 
ties, 293 

gangrene  of,  pain  in  extremi- 
ties, 310 
lower,  overburdening  of,  pain 

in  extremities,  347 
lower,  overburdening  of,  pain 

in  sacrum,  77 
Extremities,  pain  in,  257 
Eye,  diseases  of,  headache,  536 


P 


Farcy.    See  Glanders. 
Fasciitis  plantaris,  pain  in  ex- 
tremities, 343 
Feet,  cold,  295 
pains  in,  359 

Fever  and  angina  pectoris,  71 
exanthematous,  headache,  552 
exanthema tous,   muscular 

pains,  378 

exanthematous,    pain    in    ex- 
tremities, 338 

recurrent,  articular  pains,  460 
recurrent,  headache,  552 
recurrent,     muscular     pains, 

378 

recurrent,  pains  in  sacrum,  82 
recurrent,  trismus  in,  384 
Fingers,  drumstick,  436 
elongation  of,  or  acromegaly, 

440 

Flatfoot,  or  dysbasia,  304 
pain  in  extremities,  304 
pain  in  knee  joint,  507 
pain  in  small  of  back,  77 
Flatulency,  feeling  of  constric- 
tion in  throat,  188 
headache,  543 
paresthesia     in     extremities, 

275 
Fossa,  supraclavicular,  pains  in 

extremities,  327 
Furunculosis,  pains  in  extremi- 
ties, 260 
pains  in  nape  of  neck,  189 

G 

Gall  flstulae,  pain  in  bones,  408 
Gastric  crises,  tabetic  or  status 
anginosus,  72 


580 


INDEX 


Gastritis.    See  Stomach. 
Gastroenteritis,  pain  in  extrem- 
ities, 340 

Gastroptosis,  pain  in  chest,  220 
Gastroxynsis,  headache,  548 

or  migraine,  562 
Giantism,  or  acromegaly,  439 
Girdle  sense,  painful,  204 
Glanders,  articular  pain,  464 

headache,  556 

muscular  pain,  376 

pain  in  bones,  417 

pain  in  extremities,  260 
Glands,  fever  in,  pain  in  neck. 
171 

internal  secretory,  diseases  of, 
pain  in  extremities,  261 

internal  secretory,  diseases  of, 
paresthesia  in  extremities, 
286 

internal  secretory,  diseases  of, 

retrosternal  pains,  230 
Glaucoma,  headache  in,  or  mi- 
graine, 566 

headache,  nocturnal,  514 

see  also  Eye. 
Globus  hystericus,  185 
Gonorrhea,  muscular  pain,  376 

pain  in  bones,  399 

pains  in  sacrum,  83 
Gout  and  articular  rheumatism, 
489 

and  migraine,  567 

angina  pectoris  in,  35 

arthralgia  in,  498 

articular  pain,  468,  478,  485 

headache,  386,  543 

lead,  articular  pains,  498 

laterosternal  pain,  233 

muscular  pain,  358 

pain  in  back,  154 

pain  in  bones,  398,  428 

pains  in  chest,  211 

pain  in  extremities,  332,  338 

pain  in  extremities,  lancinat- 
ing, 350 

pain  in  sacrum,  77 

pain  in  shoulder,  105 

tophi,  488 
Groin,  pain  in,  360 
Growth,    abnormal,    arthralgia 
in,  499 

abnormal,  pains  in  bones,  426 


Growth,  abnormal,  pains  in  ex- 
tremities, 347 
Gullet.    See  Esophagus. 


Habitus    asthenicus,    pains    in 

sacrum,  77 

Habitus    scrofulosus,    or    acro- 
megaly, 442 
Hands,  cold,  295 
Hands,  pains  in,  359 
Hay  asthma.     See  Asthma. 
Hay  fever,  headache,  552 
Headache,  509 

and   increased   cerebral   pres- 
sure, 530 

due  to  bad  housing  and  poor 
living,  551 

due  to  strong  light  overhead, 
551 

during  period  of  pubescence, 
533,   550 

hereditary,  559 

in  cranial  sutures,  551 

induration,  513 

localization      of,      diagnostic 
value  of,  568 

nocturnal,  514 

posttraumatic,  515 

school,  550 

vasomotoric,  531 
Head's  zones,  195 
Heart,    aneurysm    of,     cardiac 
pain,  5 

debility  of,  pain  in  shoulders, 
126 

dilatation  of,  pain  in  shoul- 
der, 140 

diseases    of,    angina   pectoris 
in,  27,  37 

diseases  of,  cardiac  pain,  an- 
ginoid,  17 

diseases  of,  retrosternal  pain, 
221 

displacement     of,     abnormal, 
cardiac  pain.  0 

dissociation  of.  headache,  549 

extrasystolic      condition      of, 
cardiac  pain,  6 

fatigue  of    (over -stretching), 
cardiac  pain,  3 


INDEX 


581 


Heart,  hyperexcitation  of,  car- 
diac pain,  4 

insufficiency  of,  feeling  of  con- 
striction in  throat,  187 
insufficiency  of,  headache,  550 
insufficiency   of,    pain    in    ex- 
tremities, 320 

rupture  of,  cardiac  pain,  23 
spatial    constriction,    cardiac 

pain,  11 

thrombus  in,  pain  in  extrem- 
ities, 312 
tumors  of,  pseudoangina  pec- 

toris  in,  49 
Heat-stroke,  headache,  551 

muscular  spasms,  tetanic,  393 
Hemarthros  in  hemophilia,  476 
Hemarthros  in  spontaneous 

fracture  of  bones,  477 
in  scurvy,  477 
Hematoma,      subphrenic.       See 

diaphragm, 
subcutaneous,  pains  in  chest, 

199 

subcutaneous,    pains    in    ex- 
tremities, 260 

Hematomyelia,    pains    in    sac- 
rum, 90 

Hematomyelia,     pains     in     ex- 
tremities, 332 
Hemicranic  state,  565 
Hemoglobinuria,       paroxysmal, 

articular  pains,  460 
paroxysmal,  muscular  pains, 

380 

paroxysmal,  pains  in  extrem- 
ities, 325 
due    to    marching,    pain    in 

muscles,  380 
Hemophilia,  articular  pain,  467, 

476 
Hemorrhages,  cessation  of,  pain 

in  the  head  after,  529 
Hemorrhoids,  pains  in  sacrum, 

101 

Hernia,  diaphragmatic.  See  dia- 
phragm. 

obturatoria,  pain  in  extremi- 
ties, 325 

Herpes  zoster,  pains  in  chest, 
203 


Humerus,  inflammation  of, 
chronic,  pain  in  shoulder,  106 
neoplasm  of,  pain  in  shoulder, 
106 

Hydrophobia,    pain    in    throat, 

see  also  Rabies. 
Hydrops,  chronic  articular,  ar- 
ticular pain,  479,  500 
resorption  of,  articular  pain, 

460 
Hygroma,  pain  in  foot  (hand), 

360 
Hypertension,   arterial,  cardiac 

pain,  anginoid,  18 
arterial,    essential,    pareathe- 

sia  in  extremities,  283 
arterial,  headache,  534 
arterial,  migraine  in,  568 
Hyperthyreoidism,         articular 

pain,  490 
cardiac  pain,  16 
headache,  535 
muscular  pain,  370 
Hypophysis,   diseases  of,  head- 
ache, 518 
tumors    of,    muscular    pain, 

370 

tumors  of,  pain   in   extremi- 
ties, lancinating,  352 
Hypotension,      arterial,      head- 
ache, 534 

Hysteria,  arthralgia  in,  496 
cardiac  pain,  35 
feeling     of     constriction     in 

throat,  185 
headache,  510,  521 
headache,  nocturnal,  514 
laterosternal  pain,  233 
muscular  spasms,  tetanic,  388 
or  migraine,  568 
or  osteomalacia,  445 
pain  in  chest,  201,  246 
pain  in  extremities,  346 
pain  in  sacrum,  91 
pain  in  shoulder,  112 
paresthesia     in     extremities, 

294 
trismus  in,  383 


Icterus,  headache,  548 

Icterus  gravis,  trismus  in,  385 


582 


INDEX 


Infectious     diseases,     articular 

pain,  457 

arthralgia  in,  500 
headache,  521,  552 
muscular  pain,  376 
muscular  pain  after,  381 
muscular  spasms,  tetanic,  392 
pain  in  bones,  428 
pain  in  extremities,  333 
pleurodynia  after,  381 
percussion     sensitiveness     in 

bones,  430 
triamus  in,  383 
Influenza,  headache,  552 
muscular  pain,  377 
pain  in  bones,  428 
pain  in  chest,  215 
pain  in  extremities,  338 
pain  in  sacrum,  80 
pain  in  throat,  170 
trismus  in,  384 

Intestinal          autointoxication, 
paresthesia  in  extremities, 
276 
Intestinal    diseases,    pseudoan- 

gina  pectoris,  60 
Intestinal   parasites,   headache, 

548 

headache,  or  migraine,  362 
Intestine,  axial  tortion  of,  pain 

in  sacrum,  98 

Intestines.    Sec  Rectum,  Flatu- 
lence. 

Intrapelvic  disease,  pain  in  ex- 
tremities, 299 
Intraperitoneal  disease,  pain  in 

extremities,  323 
Ischias,  362 

or  dysbasia,  301 
or  ponitis,  473 
or  lumbago,  338 
or     rheumatism     of     gluteal 
muscles,  508 


Joints,  diseases  of,  pain  in  knee 

joint,  507 
hip,  arthritis  of,  or  ischias, 

507 
arthritis  of,  or  osteomyelitis, 

607 


Joints,  hip,  arthritis  of,  or  of 

sacroileac  joint,  607 
pain  in  flatfoot,  507 
knee,   pain   in.   in  disease  of 

hip  joint,  307 
neuralgia    of,    arthralgia    in, 

sacroileac.     See  Articulation, 
eternoclavicular,   diseases   of, 
pain  in  chest,  220 

K 

Kidneys,  diseases  of,  headache, 

540 
diseases  of,  pain   in  sacrum, 

93 
Ktimmel's     disease,     pains     in 

back,  159 


Leprosy,  swelling  in  bones,  435 
Leptomeningitis.     See  Meningi- 
tis. 

L  e  u  c  e  m  i  a,    enlargement    of 
glands,  pain  in  joints,  467 

headache,  557 

or  myeloma,  412 

pain  in  bones,  412,  426 

pain  in  joints,  466 

pain  in  sacrum,  82 

percussion     sensitiveness     in 

bones,  426 

Limping,  intermittent,  pain   in 
back,  161 

intermittent,  pain  in  extrem- 
ities, 299 
Lipoma,    pain    in    extremities, 

202 

Liver,  abscess  of,  pain  in  shoul- 
der, 114 

abscess  of,  perforation  of, 
into  pleura,  pains  in  chest, 
251 

diseases  of,  laterosternal  pain, 
233 

diseases  of,  pain  in  back,  168 

diseases  of,  pain  in  nape  of 
neck,  194 

diseases  of,  pain  in  shoulder, 
145 


INDEX 


583 


Liver,  diseases  of,  retrosternal 

pain,  229 
echinococcus      of,      pain      in 

shoulder,  114 

peracute  congestion  of  blood 
in,    pseudoangina    pectoris 
in,  55 
sarcoma  of,  pain  in  shoulder, 

115 
spirillosis    of,    cardiac    pain, 

56 

syphilis  of,  pseudoangina  pec- 
toris in,  54 
Lues.     See  Syphilis. 
Lumbago,  or  ischias,  338 
or  myeloma  of  bones,  368 
pain  in  sacrum,  74 
Lumbar     puncture,     headache, 

521 
Lung,  actinomycosis  of,  pain  in 

chest,  199 
carcinoma     of,     retrosternal 

pain,  224 

cavern     of,     perforation     of, 
through    pectoral    wall    or 
empyema  necessitatis,   198 
cavern    of,    perfororation   of, 
through    pectoral    wall    or 
pulmonary  hernia,  198 
cavern     of,     perforation     of, 
through    pectoral    wall    or 
subcutaneous  abscess,   198 
cavern     of,     perforation     of, 
through  the  pectoral  wall, 
pain  in  chest,  198 
diseases    of,    muscular    pain, 

383 

diseases  of,  pain  in  extremi- 
ties, 327 
diseases  of,  pain  in  nape  of 

neck,  193 
diseases    of,    pleurodynia    in, 

243 
diseases  of,  pain  in  shoulders, 

112,  120 

echinococcus    of,    perforation 
of,  into  the  pleura,  pain  in 
chest,  251 
echinococcus    of,    pleurodynia 

in,  243 

emphyseiTv    of,   articular 
pains,  472 


Lung,   emphysema  of,   pain   in 

bones,  429 

emphysema    of,    pain    in    ex- 
tremities, 346 

emphysema      of,      percussion 
sensitiveness  of  bones,  429 
infarct  of,  pain  in  back,  164 
infarct    of,    pleurodynia    in, 

244 

neoplasms  of,  pain  in  shoul- 
der, 143 

tuberculosis  of,  headache,  558 
tuberculosis     of,     pains     in 

shoulders,  127,  143 
tuberculosis    of,    paresthesia 

in  extremities,  267 
tuberculosis    of,    pleurodynia 

in,  243 
Lymphadenia  of  bones,  Nothna- 

gel,  pain  in  bones,  425 
Lymphadenitis,  pain  in  extrem- 
ities, 320 

Lymphangitis,  pain  in  extremi- 
ties, 320 

Lymphatic   glands,   diseases   of 

bronhial,  pain  in  neck,  171 

bronchial  diseases  of,  pain  in 

shoulder,  120 

bronchial,  perforation  of,  car- 
diac pain,  23 

bronchial  perforation  of,  re- 
trosternal pains,  222 
dorsal,    diseases    of,   pain    in 

back,  161 
mediastinal,  inflammation  of, 

pain  in  chest,  246 
mediastinal,  inflammation  of, 

pain  in  shoulder,  129 
mediastinal,  neoplasm  of, 

pains  in  shoulder,  131 
mediastinal,  perforation  into 
the  air  passages,  retroster- 
nal pain,  249 

mediastinal,    perforation    of, 
into  the  aorta  or  pericar- 
dium, retrosternal  pain,  249 
mesenteric,  diseases  of,  pain 

in  the  sacrum,  95 
of     neck,     inflammation     of, 

pain  in  neck,  170,  183 
retrosternal,    diseases    of    re- 
trosternal pain,  222 


584 


INDEX 


Lymphatic  glands,  nuchal,  dis- 
eases of,  pains  in  nape  of 
neck,  192 

retro  peritoneal,    diseases    of, 
pain  in  sacrum,  95 

swelling  of,  in  acute  leucemia, 
455 

swelling  of,  in  articular  rheu- 
matism, 455 

swelling    of,    in    Still-Chauf- 
fard's  disease,  455 

swelling  of,  in  syphilitic  ar- 
thritis, 455 

Lyssa.     See  also  Rabies, 
pain  in  throat,  185 

M 

Malaria,  arthralgia  in,  498 
headache,  552,  557 
muscular  pain,  378 
muscular  spasms,  tetanic,  392 
paresthesia     in     extremities, 

288 
percussion     sensitvieness     in 

bones,  430 
pleurodynia  in,  236 
Malleus.     See  Glanders. 
Malta    fever,    articular    pains, 

461 

headache,  556 
pains  in  bones,  418 
pains  in  sacrum,  52 
see  also  Fevers. 
Mamma,  abnormally  large,  car- 
diac pain,  1 
arteries  of,  sclerosis  of,  pain 

in  chest,  202 
carcinoma  of,  pain  in  chest, 

200 

diseases  of,  pain  in  chest,  200 
hypertrophy  of,  pain  in  chest, 

200 
involution  of,  pain  in  chest, 

200 

Mania,  acute  or  rabies,  185 
Mastodynia,  pain  in  chest,  201 
Mediastinitis,  pain  in  back,  162 
pain  in  neck,  176 
pain  in  shoulder,  115,  131 
pseudoangina  pectoris  in,  50 
retroaternal  pain,  222 
retroeternal  pressure  feeling, 
232 


Mediastinum,  diseases  of,  girdle 
eense,  206 

diseases  of,  laterosternal  pain, 
233 

diseases  of,  pain  in  shoulders, 
123,  127 

tumors  of,  pain  in  chest,  244 

tumors  of,  pain  in  shoulders, 
142 

tumors  of,  pseudoangina  pec- 
toris in,  50 

tumors  of,  retrosternal  pain, 

223,  248 

Meningeal   hemorrhage,  muscu- 
lar spasms,  tetanic,  390 
Meningismus,  headache,  558 
Meningitis,     chronic,     pain     in 
sacrum,  88 

epidemic,  articular  pain,  459 

epidemic,  headache,  554 

epidemic,  pain  in  sacrum,  79 

epidemic,   paresthesia   in   ex- 
tremities, 280 

headache,  517 

muscular  spasms,  tetanic,  389 

pain  in  extremities,  332 

pain  in  nape  of  neck,  190 

pain  in  neck,  181 

serous,  headache,  518,  558 

spinal,  pain  in  back,  155 

trismus  in,  383 

tuberculous,  pain  in  sacrum, 

78,  88 

Meningo-myelitis,   pain   in   sac- 
rum, 89 

Menstruation,     articular     pain, 
474 

headache,  521,  531 

pain  in  chest,  202 

pain  in  sacrum,  99 

paresthesia     in     extremities, 

288 
Meralgia,  or  dysbasia,  304 

pain  in  extremities,  304 

paresthesia     in     extremities, 

275 

Mesentery,  diseases  of,  pain  in 
backj  168 

tearing  on,   pain   in   sacrum, 
97 

tumors   of,   pain   in   sacrum, 
97 


INDEX 


585 


Metabolic  diseases,  pains  in  ex- 
tremities, 332 

Metatarsalgia,  pain  in  extremi- 
ties, 344 
Migraine,  deuteropathic,  566 

headache,  nocturnal,  514 

or  epilepsy,  567 

or  gastroxynsis,  562 

or  gout,  567 

or   headache   due   to   uremic, 
urotoxic  causes,  559 

or   headache   in   constipation, 
562 

or  headache  in  glaucoma,  564 

or     headache     in     intestinal 
parasites,  562 

or  headache  in  nicotine  pois- 
oning, 562 

or    headache    in    sclerosis    of 
cerebral  arteries,  563 

or  hysteria,  568 

or  myalgia  of  the  head,  565 

or  occipital  neuralgia,  563 

or  pain  in  frontal  sinus,  nasal 
or  dental  region,  563 

or  trigeminal  neuralgia,  563 

pain  in  nape  of  neck,  193 

paresthesia     in     extremities, 

267 
Miliary  tuberculosis,  headache, 

553 

Mitral  stenosis  of  oatium,  an- 
gina pectoris  in,  27 

stenosis    of    oetium,    pain    in 

extremities,  312 
Mongolism,  articular  pains,  495 
Morton's  disease.    See  Metatar- 
salgia. 

Muscles,   neoplasms   of,  muscu- 
lar pain,  357 

rupture  of,  or  dysbasia,  306 

rupture  of,  pain  in  extremi- 
ties, 306 

rupture  of,  pain  in  sacrum, 

75 

Muscular  rheumatism  and  mye- 
loma of  the  bones,  357 

muscular  cramps,  353 

muscular  pain,  357,  373 

or  trichinosis,  373 

pains  in  extremities,  340 
Muscular  spasms,  tetanic,  385 


Myalgia  of  head,  headache,  512 
headache  in  or  migraine,  565 
Myalgia  or  neuralgia,  379 

pain  in  muscles,  365,  376 
Myasthenia,  paresthesia  in  ex- 
tremities, 286 
Myelitis,  pain  in  nape  of  neck, 

191 
paresthesia     in     extremities, 

279 

pain  in  extremities,  331 
pain  in  sacrum,  90 
Myeloma,   headache,  nocturnal, 

514 

muscular  pain,  357 
or  carcinoma  of  bones,  412 
or  leucemia,  412 
or  lumbago,  357 
or  muscular  rheumatism,  358 
or  osteomalacia,  412 
pain  in  bones,  412 
Myocardia,  dead  finger  in,  297 
Myocarditis,  acute,  cardiac  pain, 

3 
epistenocardiac,  cardiac  pain, 

6 
paresthesia     in     extremities, 

267 

Myomalacia,  pain  in  heart,  6 
Myositis,  articular  pain,  491 
muscular  pain,  362,  366,  373, 

375 
Myositis,  pain  in  nape  of  neck, 

190 

Myotony  or  dysbasia,  306 
pain  in  extremities,  306 
Myotyphoid,    pain    in    muscles, 

'  376 

Myxedema,  articular  pain,  491 
headache,  535 
muscular  pain,  370 
or  acromegaly,  441 
pain  in  back,  155 
pain  in  extremities,  261,  346 
pain  in  nape  of  neck,  189 
paresthesia     in     extremities, 
261,  286 


N 


Nates,  pain  in,  103 
Neck,    actinomycosis    of,    pains 
in  neck,  175 


586 


INDEX 


Neck,  feeling  of  constriction  in 
throat,  185 

phlegmon  of,  pains  in  neck, 

174 

Nephritis.    See  Nephrosclerosis. 
Nephrolithiasis,  pain  in  shoul- 
ders, 118 

Nephrosclerosis,      dead     finger, 
297 

paresthesia     in     extremities, 

267 

Nephrosis,  headache,  540 
Nerve,    cutaneous,    disease    of, 
pain  in  extremities,  265 

intercostal,    disease    of,    pain 
in  back,  161 

oculomotor.     See  Oculomoto- 
rius. 

phrenic,  neuritis  of    (neural- 
gia), angina  pectoris  in,  63 

phrenic,  neuritis  of    (neural- 
gia), cardiac  pain,  13 

phrenic,  neuritis  of,  intercos- 
tal pain,  233 

phrenic,  neuritis  of    (neural- 
gia), pain  in  neck,  182 

phrenic,  neuralgia  of,  pain  in 
shoulder,  118 

phrenic,    disease   of,    pain    in 

shoulder,  144 

Nerve  roots,  posterior,  diseases 
of,  or  of  nerve  trunks,  329 

diseases  of,  pain  in  extremi- 
ties, 329 

pain  in  back,  155 

diseases  of,  pain  in  nape  of 
neck,  190 

diseases  of,  pain  in  chest,  203 

diseases    of,    pleurodynia    in, 

245 

Nerve,  sympathetic,  disease  of, 
headache,  533 

trigeminal,    compression    of, 
headache,  513 

trigeminal,   neuralgia   of,   or 
angina  pectoris,  69 

trigeminal,  neuralgia  of, 
headache,  513 

vagus,    irritation    of,    feeling 
of  constriction  in  neck,  187 

vagus,    neurosis    of,    pseudo- 
angina  pectoris,  64 


Nerve-trunk,   lesion   of,   or   of 
nerve-roots,  329 

lesion  of,  pain  in  extremities, 

322 
Nerves,  diseases  of,  321 

mechanical   injury  of,   pares- 
thesia  in  extremities,  272 
Nervous  system.     See  Plexus. 
Neuralgia,    intercostal,    or    an- 
gina pectoris,  62 

intercostal,  pain  in  chest,  202 

intercostal,  pain  in  shoulder, 
121 

lumbo-abdominal,  pain  in  sac- 
rum, 78 

occipital,  headache,  310 

occipital,  headache  in  or  mi- 
graine, 565 

occipital,  or  angina  pectoris, 
69 

of  trigeminal  nerve,  or  angina 
pectoris,  69 

or  arthritis  deformans,  483 

of  trigeminal  nerve,  headache, 
513 

thoraco-brachial,    or    angina 
pectoris,  62 

see  Myalgia 

Neurasthenia  and  cerebral   ar- 
teriosclerosis, 521 

arthralgia  in,  495 

girdle  sense  in,  205 

muscular  pains,  369 

or  dysbasia,  303 

or  acromegaly,  443 

or    cerebral    arteriosclerosis, 
521 

pain  in  back,  156 

pain  in  cheat,  215 

pain  in  extremities,  303,  331 

pain  in  sacrum,  90 

pain  in  shoulder,  112,  121 

parestheaia     in     extremities, 
295 

retrosternal  pain,  231 
Neuritis,  articular  pain,  472 

muscular  pain,  362 

muscular  spasms,  353 

or    acute    articular    rheuma- 
tism, 472 

or  arthritis  defonnans,  483 

or  dysbasia,  301 

or  phlebitis,  357 


INDEX 


587 


Neuritis,    pain    in   extremities, 

301,  321,  332 

pain  in  extremities,  lancinat- 
ing, 350 
paresthesia     in     extremities, 

273 
brachial,    pain    in    shoulder, 

107 

Neurofibromatosis,  pain  in  ex- 
tremities, 262 
Neuromyositis,    muscular   pain, 

371 

Neurosis,  cardiac  pain,  15 
climacteric,  anginoid  cardiac 

pain,  15 
occupational,        muscular 

cramps,  353 

occupational,  or  dysbasia,  291 
occupational,    paresthesia    in 

extremities,  353 
pain  in  back,   156 
pain  in  shoulder,  112,  118 
pain  in  sacrum,  90 
pseudoangina  pectoris   in,   35 
vasomotoric     paresthesia     in 

extremities,  295 
Nodes,  Heberden's,  501 

Heberden's  or  gouty,  501 
Nose,  diseases  of,  headache,  537 
diseases   of,   headache   in,  or 

migraine,  562 

Nuchal  muscles,  diseases  of, 
pain  in  shoulder,  139 

O 

Obstipation,  arthralgia  in,  498 

Ochronosus,  articular  rheuma- 
tism in,  articular  pain,  484 

Oculomotorius,  paralysis  of, 
periodic,  headache  in  or 
migraine,  567 

Omagra,  pains  in  joints,  468 
pain  in  shoulder,  105 

Omalgia,  pain  in  shoulder,  107 

Omarthritis,  pain  in  shoulder, 
105 

Oral  cavity,  diseases  of,  head- 
ache, 539 

Osteoarthritis  deformana.  Sec 
Arthritis. 

Osteoarthropathy  or  arthritis 
deformans,  604 


Osteoarthropathie    hypertrophi- 

ante,  articular  pain,  504 
Marie's,  436 
pain  in  bones,  422 
Osteoarthropathy     or     acrome- 

paly,  422 
Osteocopic  pains.   See  Pains  in 

Bones. 
Osteogenesis    imperfecta   tarda, 

pain  in  bones,  425 
Osteomalacia,  girdle  sense,  205 
or  hysterical  pseudoosteoma- 

lacia,  445 
or   arthritis   deformans,   444, 

505 

or  Paget's  ostitis,  421 
or    spastic    spinal    paralysis, 

445 

or  spinal  arteriosclerosis,  444 
or  spondylarthritis,  444 
or  syphilis  of  bones,  444 
pain  in  bones,  407 
pain  in  sacrum,  87 
paresthesia     in     extremities, 

267,  288 
Osteomyelitis,      arthralgia     in, 

498 

mitigated,  475 
or  acute  arthritis,  470 
or     arthritis     of     sacroileac 

joint,  508 
or  ischias,  508 

or  muscular  rheumatism,  508 
or  omartnritis,  507 
pain  in  bones.  415 
pain  in  shoulder,  106 
percussion     sensitiveness     in 

bones,  429 
Osteopathy,    hunger,    headache, 

514 

hunger,  pain  in  bones,  407 
Osteoperiostitis,    actinomycotic, 

pain  in  bones,  418 
malleosa,  pain  in  bones,  417 
pain  in  bones,  396 
syphilitic,  pain  in  bones,  414 
Osteoporosis    or    arthritis    de- 
formans, 505 
pain  in  bones,  283 
paresthesia  in  extremities,  266 
Osteopsathyrosis,    articular 

pain,  491 
brittleness  of  bones,  432 


588 


INDEX 


Osteotabes,     Ziegler,     pain     in 

bones,  425 
Ostitis     deformans,     headache, 

nocturnal,  514 
or  acroraegaly  or  hyperosto- 

sis,  420 

or  neoplasm  of  bones,  421 
or  ostitis  gummosa,  420 
or  senile  osteomalacia,  421 
Paget,  articular  pain,  491 
Paget,  pain  in  bones,  402,  419 
Ostitis    fibrosa,    headache,    403, 

422 

Ostitis,  pain  in  bones,  395 
Ostitis     melitensis,     pain     in 

bones,  419 
Ostitis,     syphilitic,     or     acute 

arthritis,  471 
syphilitic,  or  Paget's  ostitis, 

421 
tuberculous,    pain    in    bones, 

415 
Ostitis  typhosa,  pain  in  bones, 

418 

Overexertion,  pain   in  extremi- 
ties, 347 
Overfatigue,     muscular     pains, 

380 

pain  in  chest,  211 
paresthesia     in     extremities, 

266 

Overwork,  headache,  532 
Oxalemia,  articular  pain,  490 
Oxaluria,  articular  pain,  490 


Pachydermia.    See  Acromegaly. 
Pachymeningitis,  headache,  517 
or  leptomeningitis,  517 
pain  in  extremities,  332 
Pain,  anginoid,  14 
rheumatoid,  431 
Pancreas,   diseases  of,   pain   in 

sacrum,  92 
necrosis  of,  pseudoangina  pec- 

toris  in,  57 
diseases  of,  retrosternal  pain, 

228 

diseases  of,  pain  in  back,  168 
diseases  of,  pain  in  shoulder, 
144 


Pancreas,  sarcoma  of,  pain  in 

sacrum,  96 
sarcoma  of,  pseudoangina  pec- 

toris  in,  57 
Pancreatitis,  pseudoangina  pec- 

toris  in,  57 

Pappataci  fever,  headache,  553 
muscular  pain,  379 
pains  in  nape  of  neck,  190 
Paralysis    agitans,    or    chronic 
articular    rheumatism,  503 
paresthesia     of     extremities, 

286 
Paralysis,  progressive,  headache, 

525 

progressive,  migraine  in,  566 
progressive,  pains  in  extremi- 
ties, 331 
Paratyphoid,     articular     pains, 

451,  463 
headache,  553 
muscular  pain,  376 
Parotitis,  headache,  552 

epidemic,  pains  in  neck,  177 
Pectoral    muscles,    diseases    of, 

pain  in  chest,  218 
rheumatism      of,     pains     in 

chest,  211 
Pedalgia,  pains  in  extremities, 

345 
Peliosis,     rheumatic,     articular 

pains,  467 

Pellagra,  pains  in  back,  155 
pains  in  extremities,  333 
pains  in  extremities,  559 
pains  in  sacrum,  102 
paresthesia     of     extremities, 

290 

trismus  in,  385 
Pelvis,     anomalies     of,     sacral 

pain,  85 
small,  diseases  in,  arthralgia 

in,  497 

small,  disease  of,  pains  in  ex- 
tremities, 323 
tumors  in,  lancinating  pains 

in  extremiites,  352 
Periarteritis    nodosa,    articular 

pains,  466 
muscular  pains,  380 
pains  in  extremities,  315,  339 
Pericarditis,  angina  pectoris  in, 
27 


INDEX 


589 


Pericarditis,     acute,     cardiac 

pain,  5,  21 

adhesive,     ( concretio     p  e  r  i- 
cardii  cum  corde),  angina 
pectoris  in,  7 
epistenocardiac,  or  status  an- 

ginosus,  71 
epistenocardiac,  pain  in  heart, 

5 

pain  in  the  heart,  8 
pain  in  shoulders,  114,  117 
pleuro-,  pain  in  throat,  21 
retrosternal  pain,  223 
Pericardium,    perforation    into, 

angina  pectoris  in,  51 
Perigastritis,  pain  in  heart,  25 
pseudoangina  pectoris  in,  51 
pain  in  shoulders,  116 
pleurodynia  in,  237 
Periostitis,     acute     rheumatic, 

pain  in  bones,  419 
albuminous,    pains    in    bones, 

417 

Peripleuritis.     See  Abscess, 
pain  in  shoulder,  117 
subdiaphragmatic,  lateroster- 

nal  pain,  234 
subdiaphragmatic,     pain     in 

nape  of  neck,  194 
subdiaphragmatic,     pain     in 

shoulders,  144 

Pertussis,  retrosternal  pain,  225 
Pea  planus.     See  Flatfoot. 
Pharynx,  diseases  of,  "headache, 

539 

Phlebitis,  muscular  pain,  362 
or  dermatomyositis,  375 
or  hysteria,  358 
or  neuritis,  358 
see  also  Veins. 

Phlebosclerosis,  pain  in  extrem- 
ities, 319 
Phlegmon  of  the  skin,  pain  in 

extremities,  264 
subpectoral,    pain    in    shoul- 
ders, 111 
Pilocarpin,    injection    of,    angi- 

noid  pain  in  heart,  18 
Plague,  headache,  81 
muscular  pain,  378 
pain  in  extremities,  321 
pain  in  nape  of  neck,  193 
pain  in  sacrum,  81 


Pleura,   actinomycosis   of,  pain 

in  chest,  199 
diseases  of,  pain  in  nape  of 

neck,  194 
diseases  of,  pain  in  shoulder, 

120 
echinococcus    of,    perforation 

of  into  the  lungs,  pectoral 

pain,  251 
neoplasms  of,  pain  in  chest, 

238 

syphilis  of,  pain  in  chest,  242 
Pleurisy.    See  Pleuritis. 
Pleuritis,  diaphragmatic,  pains 

in  back,  164 
diaphragmatic,  pain  in  chest, 

250 
diaphragmatic,  pains  in  nape 

of  neck,  194 

diaphragmatic,  pains  in  sac- 
rum, 77 
diaphragmatic,     pains     in 

shoulder,  116,  144 
diaphragmatic,      pleurodynia 

in,  238 
fibrous     adhesive,    pains    in 

back,  164 
fibrous     adhesive,     pain     in 

chest,  238,  244 
fibrous     adhesive,     pain     in 

heart,  8 

fibrous  adhesive,  pain  in  sac- 
rum, 77 
interlobar,  pain  in  shoulders, 

132,  144 

mediastinal,  cardiac  pains,  21 
mediastinal,    pains    in    back, 

161 
mediastinal,    pain    in    chest, 

238 
mediastinal,  pain  in  shoulder, 

129,  132 

pain  in  back,  161 
pain  in  chest,  215,  250 
pain  in  shoulder,  114,  117 
perforation  of  into  lung,  pain 

in  chest,  250 
Pleuritis  sicca    (dry  pleurisy), 

angina  pectoris  in,  31 
cardiac  pain,  anjinoid,  20 
muscular  pain,  383 
pain  in  chest,  212 
and  pleurodynia,  234 


590 


INDEX 


Pleuro-pericarditis.      See    Peri- 
carditis. 
Pleurodynia,  234 

pains  in  chest,  211 
Plexus,   nervous   brachial,   neu- 
ritis of,   pain   in   shoulder, 
107 

nervous  celiac,  neuralgia  of, 
pain  in  sacrum,  98 

nervous  cervico-brachial,  dis- 
eases of,  pain  in  shoulder, 
141 

nervous  cervico-brachial,  neu- 
ritis of,  pain  in  shoulder, 
108,  141 

nervous  cervico  -  occipitalis, 
neuralgia  of,  pain  in  nape 
of  neck,  192 

nervous  aortic,  neuritis  of, 
and  angina  pectoris,  68 

venous  pelvic,  ectasy  of,  pain 
in  sacrum,  98 

venous  pelvic,  thrombosis  of 
( thrombophlebitis ) ,    pain 
in  sacrum,  98 
Pneumonia,  headache,  558 

muscular  pain,  377 

pain  in  nape  of  neck,  194 

pain  in  shoulder,  132,  143 

pleurodynia  in,  235 
Pneumothorax  and  pleurodynia, 
242 

or  diaphragmatic  hernia,  250 

pain  in  chest,  250 

pains  in  shoulder,  114 
Poisoning,     alcohol,     headache, 
521,  531,  544 

alcohol,  muscular  pain,  369 

and  muscular  spasms,  355 

and  muscular  spasms,  tetanic, 
390 

arsenic,  headache,  544 

arsenic,  pain  in  bones,  428 

arsenic,  paresthesia  in  ex- 
tremities, 289 

atropin,  feeling  of  constric- 
tion in  throat,  188 

atropin,  trismus  in,  384 

blood  poisoning,  trismus  in, 
385 

carbon  oxid,  angina  pectoris 
in,  33 

carbon  oxid,  headache,  544 


Poisoning,     chloroform,     head- 
ache, 531,  544 
chromic  acid,  pain  in  bones, 

428 

coffee,  angina  pectoris  in,  33 
coffee,  headache,  544 
ergot,    muscular   cramps,   te- 
tanic, 391 

ergot,  paresthesia  in  extrem- 
ities, 288 

lead,  angina  pectoris  in,  33 
lead,  arthralgia  in,  498 
lead,  headache,  544 
lead,  muscular  pains,  370 
lead,    muscular    spasms,    te- 
tanic, 389 

lead,  pain  in  sacrum,  99 
lead,  paresthesia  in  extremi- 
ties, 289 

mercury,  headache,  544 
mercury,  muscular  pains,  371 
mercury,  pains  in  bones,  428 
nicotine,  cardiac  pain,  14 
nicotine,  headache,  531,  544 
nicotine,  headache  in,  or  mi- 
graine, 562 
nicotine,  lancinating  pains  in 

extremities,  351 
nicotine,    paresthesia    in    ex- 
tremities. 289 
nicotine,  trismus  in,  385 
nitrite,  headache,  531,  544 
nitrobenzol,  headache,  544 
opium    (morphin),   muscular 

spasms,  tetanic,  391 
opium  (morphin),  trismus  in, 

385 

pains  in  extremities,  332 
perchloride   of   mercury,   car- 
diac pains,  14 
phosphorus,    pain    in    bones, 

428 

retrosternal  pains  in,  226 
strychnin,    muscular    spasms, 

tetanic,  386 

sublimat,  muscular  pains,  371 
sulphurous  carbon,  headache, 

544 

sulphurous   carbon,  paresthe- 
sia in  extremities,  274 
tea,  angina  pectoris  in,  32 
tea,  headache,  531,  544 


INDEX 


591 


Poisoning,    tea,    paresthesia    in 

extremities,  296 
tea,  trismus  in,  385 
vanilla,  headache,  544 
Poliomyelitis,    muscular     pain, 

379 

or    acute    articular    rheuma- 
tism, 473 

pain  in  extremities,  332 
pain  in  nape  of  neck,  191 
pain  in  sacrum,  79,  88 
Polyarthritis.     See  Arthritis. 
Polycythemia,  migraine  in,  568 

rubra,  headache,  528 
Polymyositis,     muscular     pain, 

371 

pain  in  chest,  211 
Polyneuritis.     See  Neuritis. 
Posture  of  body,  forward  lean- 
ing, retrosternal  feeling  of 
pressure  in,  232 
Pregnancy,  headache,   541 
pains  in  chest,  202 
pains  in  sacrum,  76 
paresthesia     in     extremities, 

270 
toxic  condition  in,  headache, 

541 
Pseudoacromegaly  in  pregnancy 

or  acromegaly,  440 
Pseudoangina  pectoris.    See  An- 
gina Pectoris. 
Pseudoosteomalacia,    hysterical 

or  osteomalacia,  445 
Pseudoperiostitis,      angioneuro- 

tic,  399 
Pseudorheumatism,     infectious, 

articular  pains,  457,  480 
Pseudotabes,    peripheral,    pains 
in  extremities,  lancinating, 
352 

Pseudotetanus,  392 
Pseudotetany,    hysterical,   mus- 
cular cramps,  353 
Pseudotrismus,  382 
Psoriasis,  articular  pains,  490 
cardiac  pain,  anginoid,  17 
headache,  527 
pain  in  shoulder,  112 
Puberty,  headache,  533,  550 
Purpura,  heniorrhagica,  articu- 
lar pain,  467 


Pyelitis  and  pleurodynia,  237 

pain  in  sacrum,  83 
Pyemia,  muscular  pain,  376 
Pylorus  stenosis,  colic,  pseudo- 
angina  pectoris  in,  60 
Pyopneumothorax,     pain     in 

chest,  242,  251 
Pyothorax.     See   Empyema. 

pain  in  chest,  258 
Pyrgocephalus,  headache,  514 

migraine  in,  567 
Pyrosis,  retrosternal  pain,  228 

Q 

Quicksilver.     See  Mercury  pois- 
oning. 

R 

Rabies,    constriction,    girdle 

sense  in  throat,  185 
muscular  spasms,  tetanic,  387 
or  acute  mania,  185 
or  hydrophobia,  185 
pain  in  sacrum,  90 
paresthesia     in     extremities, 

280 
Rachitis    tarda,    arthralgia   in, 

498 

pain  in  bones,  403,  408 
Raynaud's   disease,    paresthesia 

in  extremities,  271 
Recklinghau$en's    disease,    pain 

in  bones,  422 

Rectum,  diseases  of,  pain  in  sac- 
rum,  101 
Renal  colic,  pains  in  sternum, 

234 
Respiratory  organs,  diseases  of, 

headache,  548 
Retroperitoneal    diseases,    liv«r 

complaint  in,  168 
pain  in  back,  165 
pain  in  extremities,  323 
pain  in  sacrum,  92  S. 
see  also   Cellulitis  and   Lym- 
phatic Glands. 
Rheumatism.  See  Articular  and 

Muscular  Rheumatism. 
Rheumatismus  articulorum  no- 
dosus,  articular  pains,  446 


592 


INDEX 


Rhizomyelia.      See    Spondylar- 

thritis. 
Ribs,  disease  of,  or  dyspragia, 

308 

diseases  of,  pain  in  back,  154 
diseases  of,  pain  in  chest,  215 
diseases  of,  pain  in  neck,  308, 

328 
diseases   of,  pain  in   sacrum, 

86 
diseases  of,  pain  in  shoulder, 

125 

cervical,    paresthesia    of    ex- 
tremities, 309 

Rigor  produced  by  heat,  muscu- 
lar spasms,  tetanic,  394 


S 


Sacral     muscles,     diseases     of, 

pain  in  sacrum,  73 
Sacrum,    diseases    of,    pain    in 

sacrum,  88 
Scapula,    diseases    of,    pain    in 

shoulder,  119 

diseases  of,  pain  in  back,  159 
Scapular  crackling  sound,  119 
Scarlatina,    paresthesia    of    ex- 
tremities, 288 
pressure    sensitiveness    in 

bones,  430 

Scarlet  fever.     See  Scarlatina. 
Sclerodermia,    articular    pains, 

491 

nuchal  pains,  189 
or  chronic  articular  rheuma- 
tism, 504 

pain  in  extremities,  265 
Sclerosis     insularis     multiplex, 

arthrology  in,  495 
articular  pains,  472 
headache,  518 
migraine  in,  566 
multiple  pains  in  chest,  205 
pain  in  extremities,  472 
pain  in  shoulders,  106 
paresthesia     in     extremities, 

267,  278 

Scurvy,  articular  pain,  467 
hemarthros  in,  477 
muscular  pain,  380 
pain  in  bones,  425 


Scurvy,  pains  in  chest,  215 

pain  in  extremities,  341 
Sepsis,  headache,  556 
meningococcal,  articular  pain, 

451 

muscular  pains,  377 
pains  in  back,  160 
pain  in  chest,  216 
pains  in  extremities,  340 
pains  in  nape  of  neck,  190 
percussion      painfulness      i  n 

bones,  430 
pneumococcal,  articular  pains, 

451 

sacral  pains,  82 
Serum  sickness,  articular  pains, 

460 
Sexual  organs,  female,  diseases 

of,  pains  in  sacrum,  99 
male,  diseases  of,  pain  in  sac- 
rum,  101 
Shoulder,    muscles    of,    diseases 

of,  pain  in  shoulder,  107 
pain  in,  67 

Shoulder  blade.    See  Scapula. 
Sphenoid     bone,     diseases     of, 

headache,  537 
Sinus,      frontal,      diseases      of, 

headache,  537 
frontal,  diseases  of,  headache 

in,  or  migraine,  563 
Skin  dorsal,   affection  of,   pain 

in  back,  161 
pectoral,   disease  of,   pain   in 

chest,  195 

Skull,  diseases  of,  headache,  513 
Smallpox.     See  Variola. 
Spinal  column,  arthropathy  of, 

pain  in  back,  151 
articular  diseases  of,  pains  in 

nape  of  neck,  191 
diseases    of,    pains    in    back, 

147 

diseases  of,  pain  in  chest,  216 
diseases  of,  pains  in  nape  of 

neck,  191 
diseases  of,  pain  in  shoulders, 

122 
diseases  of,  pain  in  sacrum, 

86 

injury  of,  pain  in  sacrum,  88 
insufficiencv  of,  pain  in  chest, 
217 


INDEX 


593 


Spinal  Column,  neoplasms  of, 
or  spondylarthritis  anky- 
lopoietica  (arthritis  defor- 
mans),  152 

neoplasms  of,  pains  in  back, 
152 

neoplasms    of,    pains    in    ex- 
tremities, 333 

osteomalacia  of,  pain  in  sac- 
rum, 87 

scoliosis    of,    pains    in    back, 
147 

scoliosis    of,    pains    in    chest, 

209 

Spinal  cord,  arteries,  occlusion 
of,  girdle  feeling,  205 

arteries,  sclerosis  of,  or  osteo- 
malacia, 444 

diseases    of,    articular    pains, 
492 

girdle  sense,  205 

pain  in  back,  154 

pains  in  extremities,  265,  334 

pains  in  extremities,  lancinat- 
ing, 350 

pain  in  sacrum,  89 

paresthesia     in     extremities, 

265,  276 

Spinal  cord,  syphilis  of,  pain 
in  extremities,  331 

syphilis  of,  paresthesia  in  ex- 
tremities, 277 

tumors   of,  pain   in  extremi- 
ties, 332 

tumors   of,   pain   in   extremi- 
ties, lancinating,  352 

tumors  of,  pain  in  sacrum,  89 

tumors  of,  paresthesia  of  ex- 
tremities, 278 
Spinal     paralysis,     spastic,     or 

osteomalacia,  445 
Spleen,   abscess  of,  perforation 
of,  in  pleura,  pain  in  chest, 
252 

diseases  of,  laterosternal,  233 

diseases  of,  pain  in  shoulders, 
117 

extirpation  of,  pain  in  bones, 
426 

tumors  of,  pain  in  sacrum,  92 
Spondylarthritis,  ankylopoietic, 
pains  in  extremities,  332 

girdle  sense,  205 


Spondylarthritis,    or    neoplasm 

of  spinal  column,  154 
or  osteomalacia,  444 
pains  in  sacrum,  84 
pains  in  nape  of  neck,  192 
Spondylitis,     acute,     pains     in 

back,  149 

chronic,  pains  in  back,  144 
Spondylopathia,  traumatic, 

pain  in  back,  159 
Sporotrichosis,    articular    pain, 

466 

swelling  in  bones,  434 
Stenocardia.     See   Angina  Pec- 

toris. 
Sternum,   diseases  of,  pains  in 

chest,  218 

pains  behind  the,  220 
pains  laterally  to  the,  234 
feeling  of  pressure  behind  the, 

232 

Still-Chauffard's    disease,    arti- 
cular pains,  456 
swelling  of  lymphatic  glands, 

456 

Stomach,    anacidity    of,    head- 
ache, 534 
Stomach,  carcinoma  of,  pain  in 

back,  164 
pain  in  sacrum,  96 
perforation    of    into    pleura, 

pain  in  chest,  252 
pseudoangina  pectoris   in,  58 
Stomach,   catarrh   of,  headache, 

548 
dilatation  of,  acute,  headache, 

548 
dilatation  of,  acute,  pain  in 

chest,  58 

diseases  of,  pseudoangina  pec- 
toris in,  58 
diseases  of,  retrosternal  pain, 

228 
pneumatosis  of,  cardiac  pain, 

anginoid,  19 
pneumatosis      of,      pain      in 

shoulders,  134 

rupture  of,  pain  in  back,  168 
Stomach,  ulcer  of,  cardiac  pain. 

25 

headache,  53~3 
pain  in  back,    164 
pain  in  chest,  209 


594 


INDEX 


Stomach,    perforation    of,    into 
pericardium,   cardiac   pain, 
25 
perforation    of,    into    pleura, 

pain  in  chest,  252 
pseudoangina  pectoria  in,  51, 

58 

volvolus  of,  pain  in  heart,  25 
Struma,  colloid,  pains  in  bones, 

402 
hemorrhages  in,  pains  in  neck, 

180 

malignant,  pains  in  extremi- 
ties, 328 

Strumitis,  pains  in  neck,  178 
Subdiaphragmatic     d  i  s  e  a  s  e, 

muscular  pain,  381 
retrosternal  pain,  231 
Submaxillary     glands,     inflam- 
mation  of,   pains   in  neck, 
177 

Sun  stroke,  headache,  551 
Syphilis,  articular  pains,  454 
headache,  513,  557 
headache,  nocturnal,  513 
muscular  pain,  380 
of  bones,  or  osteomalacia,  443 
pains  in  bones,  430 
Syringomyelia,  arthropathy  in, 

494 

or  acromegaly,  440 
or  chronic  articular  rheuma- 
tism, 494 

pains  in  extremities,  332 
pains  in  sacrum,  90 
paresthesia     in     extremities, 

332 
see  also  Spinal  Cord. 


Tabes,  angina  pectoris  in,  34 

arthralgia  in,  497 

arthropathy  in,  493 

feeling  of  constriction  in 
neck,  188 

girdle  sense,  204 

headache,  512 

pain  in  chest,  204 

pains  in  extremities,  266,  333 

pains  in  extremities,  lancin- 
ating, 349 

pain  in  sacrum,  87 


Tabes,   paresthesia   in   extremi- 
ties, 266 
(dorsalis  et  cervicalis).     See 

also  Spinal  Cord. 
Taboparalysis,  migraine  in,  566 
Tachycardia,     paroxysmal,     an- 

ginoid  cardiac  pain,  17 
cardiac  pain,  3,  20 
feeling     of     constriction     in 

neck,  187 

in  angina  pectoris,  42 
pain  in  shoulder,  140 
paresthesia  in  extremities, 

270 
Tarsalgia,  pain  in  extremities, 

342 
Teeth,    diseases    of,    headache, 

539 
headache     in,     or     migraine, 

563 

headache,  nocturnal,  514 
Tendovaginitis,    pain    in    foot, 

pain  in  hand,  360 
Tetanus,  articular  pain,  471 
feeling     of     constriction     in 

neck,  185 

muscular  pain,  366 
muscular    convulsions,    local- 
ized, 354 

pains  in  chest,  215 
pain  in  nape  of  neck,  189 
pain    in    region    of    ensiform 
process,  220 
pain  in  sacrum,  80 
pain  in  shoulder,  126 
paresthesia     in     extremities, 

280 

trismus  in,  383 
Tetany,  cardiac  pain,  13 
muscular  cramps,  353 
muscular  spasms,  tetanic,  393 
paresthesia     in     extremities, 

269 

trismus   in,  384 
Thyreoid  eland,  insufficiency  of, 

arthralgia  in,  500 
neoplasm    of,    pain    in    neck, 

178 

Thyreoid.     See   also   Hyperthy- 
reoidism,  Hypothyreoidism, 
Strumitis. 
Thyreoid  it  is,  pain  in  neck,  178 


INDEX 


595 


Tonsilitis,  pain  in  nape  01  neck, 

193 

pain  in  throat,  173 
trismus  in,  384 
Tophi,  in  gout,  488 
Towershaped    skull.      See    Pyr- 

gocephalus. 

Trachea,   foreign   bodies  in  re- 
trosternal pain,  225 
stenosis  of,  retrosternal  pain, 

225 
Tracheiiis,     retrosternal     pain, 

224 

pain  in  shoulder,  132 
Trichinosis,  muscular  pain,  373 
or  dysbasia,  307 
or  muscular  rheumatism,  373 
pain  in  chest,  211 
pain  in  extremities,  307,  340 
pain  in  nape  of  neck,  189 
pain  in  sacrum,   82 
Trismus,  382 
Tuberculin      injection,      angina 

pectoris  in,  33 
Tuberculosis,     muscular     pain, 

381 

renal,  pain  in  sacrum,  83 
Turbinate  bone,  cavity  of,  dis- 
eases of,  headacne,  537 
Typhoid    and     acute    articular 

rheumatism,  464 
and      gonorrhoic      articular 

rheumatism,  464 
anti  -  vaccination,       articular 

pain,  463 
anti  -  vaccination,      headache, 

555 

articular  pains,  462 
bacillus  septicemia,  articular 

pains,  463 
headache,  552 
muscular  pain,  81 
pain  in  bones,  418,  428 
pain  in  extremities,  339 
percussion     sensitiveness     in 

bones,  430 
serum  inoculation,   headache, 

555 
trismus  in,  384 

U 

Uremia,  arthralgia  in,  499 
dead  finger,  296 


Uremia,  feeling  of  constriction 

in  neck,  188 
headache,  540 

headache  in,  or  migraine,  561 
headache,  nocturnal,  514 
muscular  spasms,  tetanic,  392 
pain  in  extremities,  332 
paresthesia     in     extremities, 

276 

Urinary     congestion,     pain     in 
sacrum,  93 


Vagotony,    cardiac    pain,    angi- 

noid,    19 

Variola,  articular  pains,  458 
headache,  552 
pains  in  extremities,  338 
pain  in  sacrum,   81 
Veins,   diseases   of,   paresthesia 

in  extremities,  293 
phlebitis  of,  pain  in  extremi- 
ties, 320 
thrombophlebitis  of,  pains  in 

extremities,  315 
thrombosis   of,    pains   in   ex- 
tremities, 315 
thrombosis  of,  parestnesia  in 

extremities,  293 
varicose,  pains  in  extremities, 

318 

varicose,    paresthesia    in    ex- 
tremities, 291 

see  also  Phlebosclerosis,  Phle- 
bitis, Plexus. 

Vena   cava    superior,    thrombo- 
sis   of,    pseudoangina    pec- 
toris in,  51 
thrombosis     of,     retrosternal 

pain,  221 
Venae  iliacse,  phlebitis  of,  pain 

in   sacrum,   98 

Vena    jugularis    interna,    phle- 
bitis of,  pain  in  neck,  181 
thrombosis  of,  pain  in  neck, 

181 

Venae  pelvince,  thrombosis  of 
(thrombophlebitis),  pain 
in  sacrum,  98 

ectasy  of,  pain  in  sacrum,  98 
Vertebral   column.     See  Spinal 
Column. 


596 


INDEX 


Vomiting,    feeling    of    constric- 
tion in  throat,  188 

W 

Weil's  disease,  muscular  pain, 
379 

pain  in  chest,  211 

pain  in  nape  of  neck,  189 

pain  in  sacrum,  80 

trismus  in,  384 
Windpipe.     See  Trachea. 
Wolhynian  fever,  headache,  552 

muscular  pains,  378 


Wolhynian  fever,  pain  in  nape 

of  neck,  190 
pains  in  bones,  427 
pains  in  extremities,  339 


Xiphoid  process.    See  Ensiform 
Process,  219 


Yellow  fever,  headache,  552 
muscular  pain,  379 
pains  in  sacrum,  80 


Date  Due 


PR.NTCO.N  U...A.  CAT.    NO.    24    161 


A     000453 


909 


WB176 
0  77$ 
1922 
Ortner,  Norbert. 

Clinical  symptomatology  of  internal 
diseases 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


